Rhode Island > Workers Comp > Department Of Labor And Training > Medical
Medical Fee Schedule Order Form - Rhode Island
| Medical Fee Schedule Order Form Form. This is a Rhode Island form and can be used in Medical Department Of Labor And Training Workers Comp . |
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th 125 N. Halsted 4 Floor Chicago, IL 60661 (312) 559-8445 (877) RISING4 TID #: 36-4276352 RHODE ISLAND WC FEE SCHEDULE ORDER FORM Company: ___________________________________________________________ Attn: _______________________________________________________________ Address: ______________________________________Suite: ________________ City: ____________________________State: _______ZIP:__________________ Phone: ___________________________ Fax: ______________________________ Email Address: _______________________________________________________ QUANTITY DESCRIPTION COST/UNIT AMOUNT 2003 RI Fee Schedule Book $79.95 $ RI Fee Schedule Book Previous Year: ___________ $79.95 $ 2003 RI Fee Schedule 3.5 Diskette (Txt tab and Excel) $799.95 $ 2003 RI Fee Schedule CD-ROM (Txt tab & Excel) $799.95 $ TOTAL AMOUNT $ Fill out this form clearly and return with payment. Failure to do so will cause delays or errors in shipment. Orders placed without a completed order form attached will be mailed to the address listed on the check. Payment can be made with check or money order. Please make checks payable to Rising Medical Solutions, Inc.. The check acts as your receipt. Send payment and the order form to the address above.
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