Rural Health Education and Services

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 (8 hour day) rate	$600
Overtime per hour over 8/day (prorated in 1/2 hr intervals)	80
Weekday night call rate per night	80
Weekend call rate per day (24 hours)	440
Holiday with no scheduled hours	540
Weekend/holiday hourly rate for time worked (prorated in 1/2 hour intervals)	80
OB delivery (per delivery)	200
Travel time (per hour)	40
Travel expense (cents per mile)	$0.505
Lodging (Actual)
Estimated Total

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.

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