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F.A.Q.
Contract Request Form
*
Indicates required field
Manager Name (requesting contract)
*
First
Last
Email
*
Facility Information
Facility Name
*
Tax ID
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NPI
*
Responsible Person
*
First
Last
Title
*
Email Address
*
Email address of the facility contact person
Phone Number
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Street Address
*
Line 1
Line 2
City
State
Zip Code
Country
Effective Date of Contract
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Provided Services Under Contract
*
Nuclear - Staffing Only
Nuclear - Full Service
Ultrasound
CPET
Term
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6 Months
12 Months
Equipment Provided by:
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ADT
Facility
Work Hours
*
Reason for Termination
*
with cause
without cause
Insurance Billed by:
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ADT
Facility
Lunch Period
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30 minutes
1 hour
Termination Notice
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30 days
60 days
Obligation:
*
Exclusive
Non-Exclusive
Service Fees
Mobile Services - Full Day
*
Mobile Services - Half Day
*
Mobile Services - Monthly
*
Excessive Volume / OT Fee
*
per study max # of
*
ICANL Fee (every 3 years)
*
Cardiolite (per dose)
*
Lexiscan (per unit)
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Other dosage or unit
*
Special Instructions
*
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