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Rural Health >
Kansas Locum Tenens >
Service Order Form
Address (number & street, city, state, zip):
*OB coverage not available
Billing contact person:
Job contact person:
Work site address (number & street, city, state, zip):
Billing address (number & street, city, state, zip):
Locum Tenens period:
Agreement rate (mark all applicable)
* Minimum one day pay required.
* A minimum of six weeks advance notice of the date for locum tenens service is required.
* Payments are due within 2 weeks of completion of coverage. Late payments incur a $25 per day fee.
* An invoice for a $300 KLT fund fee will be sent with the service invoice to be paid to Rural Health.
Note: By submitting this form, you have agreed to be bound by this agreement and this document will be a legally valid agreement.
Preferred e-mail address: (please be specific, i.e: email@example.com)
How did you hear about Kansas Locum Tenens? Please be specific.
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