Service Order Form

Client:

Physician:

Address (number & street, city, state, zip):

Specialty:

OB coverage required: Yes No

Billing contact person:

Telephone number:

Job contact person:

Telephone number:

Work site address (number & street, city, state, zip):

Billing address (number & street, city, state, zip):

Telephone number:

Locum Tenens period:

From:		at	o'clock	a.m.	p.m.
To:		at	o'clock	a.m.	p.m.

Agreement rate (mark all applicable)

	Coverage Rates	Units	Totals
Weekday (24hrs) (prorated in 1/2 day intervals) rate	$1000
Weekend (24hrs) (prorated in 1/2 day intervals)	$1200
Holiday pay (per day)	$200
Travel time (per hour)	40
Travel expense (cents per mile)	$0.50
Lodging (Actual)
Estimated Total

Notes:

Minimum one day pay required.

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.

Client:

By:

Title:

Date:

Preferred e-mail address:
(please be specific, i.e: tsmith@kumc.edu)

How did you hear about Kansas Locum Tenens? Please be specific.

To submit, please press

To clear the form and start over, please press

Last modified: Jul 02, 2012

Questions?

Do you have any questions? Check out our FAQs for some helpful information or for more information about "Becoming a Provider" or "Requesting Service" contact Andrea Ellis at 913-588-1228 or aellis2@kumc.edu.

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Service Order Form