Medical Fee Schedule Order Form | Pdf Fpdf Doc Docx | Rhode Island

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Medical Fee Schedule Order Form | Pdf Fpdf Doc Docx | Rhode Island

Medical Fee Schedule Order Form

This is a Rhode Island form that can be used for Medical within Workers Comp, Department Of Labor And Training.

Alternate TextLast updated: 11/30/2016

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Description

RHODE ISLAND WC FEE SCHEDULE ORDER FORM Company**:__________________________________________________________ Attn**: ______________________________________________________________ Address**: ____________________________________ Suite: _________________ City**: ___________________________State**: _____ ZIP**: ________________ Phone**: __________________________ Fax: __________________________ Email Address**: _____________________________________________________ All ** fields are REQUIRED | Other fields are optional but requested for your profile. QUANTITY DESCRIPTION COST/UNIT AMOUNT $ $ $ $ $ $ RI Medical Fee Schedule Book, Most Recent Year: ______ RI Hospital Fee Schedule Book, Most Recent Year: ______ RI Medical Fee Schedule Book, Prior Year(s): _________ RI Hospital Fee Schedule Book, Prior Year(s): _________ RI Fee Schedule CD-ROM, Year(s): _________ TOTAL AMOUNT $89.95 $89.95 $99.95 / ea $99.95 / ea $799.95 / ea Fill out this form clearly and return with payment. Failure to do so will cause delays or errors in shipment. Cost/unit includes regular shipping and handling. Payment can be made by check, credit card (Visa, MasterCard, or American Express) as well as PayPal. Please make checks payable to "Rising Medical Solutions". The check or credit card statement acts as your receipt. For orders by check: send order form and payment to Rising Medical Solutions, 325 N LaSalle St, Chicago, IL 60654 For credit card & PayPal orders: email order form to finance@risingms.com or fax order form to 312-548-0681 Payment by Credit Card (check one): ____Visa ____MasterCard ____American Express Card # __________________________________________ CCV # ____________ Exp. Date ________________ For phone orders: call our Fee Schedule order department at 312-224-1333 American LegalNet, Inc. www.FormsWorkFlow.com

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