Common Contracts
1 similar Rating Agreement contracts
RateFast Express Impairment Rating AgreementRating Agreement • February 7th, 2023
Employee Information Name (Last, First, Middle): Date of Injury (MM/DD/YYYY): Date of Birth (MM/DD/YYYY): Claim Number: Employer: Claims Administrator Information Company Name: Contact Name: Address: City: State: Zip Code: Phone: Fax: E-mail Address: NCM Name: NCM E-mail Address: Vendor Service Information Vendor Name: RateFast Contact Name: Chris Hall Address: 2360 Mendocino Ave., Ste. A2-325 City: Santa Rosa State: CA Zip Code: 95403 Phone: (707) 484-5778 Fax: (707) 921-7924 E-mail Address: express@rate-fast.com Tax ID Number: 46-1201548 Fee Agreement for Requested Service • $1125 for each body part rated, includes 50-pages chart review and MD Signature• $150 per each additional 25-page units of chart review Signature: Authorized Agent/Claims Administrator: Date:
