Alabama Comp – Southern Immediate Care Injury Treatment Pricing Agreement

Alabama Comp – Southern Immediate Care Injury Treatment Pricing Agreement
This agreement for the flat rate price ONLY refers to treatment rendered at any Southern Immediate Care locations. A comprehensive list of these locations can be found at www.southernimmediatecare.com.

The Employer agrees to pay the flat rate of $200 for evaluation and treatment of a work-related injury. This fee will cover the office visit with a medical provider (MD or NP) and will include all medically necessary treatment. This includes, but may not be limited to:
- Medical History
- Basic vital signs
If the employer is an Alabama Comp client and/or located within a 30-mile radius, the injured worker will be referred to Alabama Comp for all follow-up visits.

Please note: There is a $100 charge on all follow-up visits.

By signing below, the employer agrees to this price agreement. This bill will NOT be filed with insurance unless the insurance company has also signed the agreement.
Employer Representative Signature*

Clear
Date*

MonthDayYear
Date
Employer Representative Printed Name*
Telephone*
Email address*
example@example.com
We truly appreciate the opportunity to support your employees' health and well-being through Alabama Comp and Southern Immediate Care! Thank you for trusting us with their care!

114 Wildwood Parkway Birmingham, AL 35209 ٠ PHONE: (205) 876-2667 FAX: (205) 876-2675 Monday - Thursday - 8 a.m. - 4:30 p.m. Friday 8 a.m. - 3:30 p.m. Call 205-409-2794, option 6, for SIC Work Comp details.
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