University of Kansas Medical Center
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Physician Requesting Service:
Address (number & street, city, state, zip):
OB coverage required: Yes No
Billing contact person:
Job contact person:
Work site address (number & street, city, state, zip):
Billing address (number & street, city, state, zip):
Locum Tenens period:
A minimum of six weeks advance notice of the date for locum tenens service is required.
Note: By submitting this form, you have agreed to be bound by this agreement and this document will be a legally valid agreement.
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