Medical Courier Contract Pack
Attorney-reviewed templates. Fill in your name and rates — ready to send.
Legal Disclaimer: These are templates for reference only. Have a licensed attorney in your state review all agreements before use. Laws vary by jurisdiction and your specific business situation may require additional provisions.
Template 1 of 4
Independent Contractor Service Agreement
INDEPENDENT CONTRACTOR SERVICE AGREEMENT
This Independent Contractor Service Agreement ("Agreement") is entered into as of
[EFFECTIVE DATE] ("Effective Date") by and between:
[YOUR BUSINESS NAME], a [BUSINESS ENTITY TYPE, e.g., sole proprietorship / LLC]
organized under the laws of the State of [YOUR STATE], with a principal place of
business at [YOUR BUSINESS ADDRESS] ("Contractor"),
and
[CLIENT FACILITY NAME], a [ENTITY TYPE] located at [CLIENT ADDRESS]
("Client").
Contractor and Client are each referred to herein individually as a "Party" and
collectively as the "Parties."
─────────────────────────────────────────────────────────────────────────────────
RECITALS
─────────────────────────────────────────────────────────────────────────────────
WHEREAS, Contractor is engaged in the business of medical courier and transportation
services; and
WHEREAS, Client desires to engage Contractor to provide certain courier and logistics
services in connection with Client's healthcare operations; and
WHEREAS, the Parties desire to set forth the terms and conditions governing their
relationship;
NOW, THEREFORE, in consideration of the mutual covenants set forth herein and for
other good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, the Parties agree as follows:
─────────────────────────────────────────────────────────────────────────────────
1. SCOPE OF SERVICES
─────────────────────────────────────────────────────────────────────────────────
1.1 General Services. Contractor shall provide medical courier and transportation
services to Client as described in this Agreement, including but not limited to:
(a) Specimen Transport: Safe, timely pickup and delivery of laboratory specimens,
biological samples, blood products, and diagnostic materials, in compliance
with applicable OSHA, DOT, and IATA regulations regarding the handling of
biological materials.
(b) Medical Supplies & Equipment: Transport of pharmaceuticals, medical devices,
surgical instruments, and medical supplies between Client's facilities or
from designated suppliers to Client locations.
(c) Documents & Records: Confidential transport of medical records, lab reports,
prescriptions, and other protected health information materials in sealed,
tamper-evident packaging.
(d) Scheduled Routes: Performance of agreed-upon regular route runs on a
recurring schedule as set forth in Schedule B attached hereto, or as
mutually agreed upon in writing by the Parties from time to time.
(e) STAT Runs: On-demand, priority transport services for time-sensitive
materials. Contractor shall use commercially reasonable efforts to respond
to STAT requests within [RESPONSE TIME, e.g., 30–60 minutes] of dispatch,
subject to geographic and traffic conditions.
1.2 Service Standards. Contractor shall perform all services in a professional,
competent, and timely manner, in compliance with all applicable federal, state, and
local laws, regulations, and guidelines, including those issued by the Department of
Transportation (DOT), Occupational Safety and Health Administration (OSHA), and the
Department of Health and Human Services (HHS).
1.3 Equipment. Contractor shall provide and maintain all vehicles, equipment,
containers, and packaging materials necessary to perform the services, including
temperature-controlled transport capability where required for the materials being
transported.
─────────────────────────────────────────────────────────────────────────────────
2. TERM AND TERMINATION
─────────────────────────────────────────────────────────────────────────────────
2.1 Term. This Agreement shall commence on the Effective Date and continue for an
initial term of [INITIAL TERM, e.g., one (1) year], unless earlier terminated in
accordance with this Section.
2.2 Renewal. Upon expiration of the initial term, this Agreement shall automatically
renew for successive [RENEWAL PERIOD, e.g., one (1) year] periods unless either Party
provides written notice of non-renewal at least thirty (30) days prior to the end of
the then-current term.
2.3 Termination for Convenience. Either Party may terminate this Agreement at any
time without cause by providing the other Party with at least thirty (30) days' prior
written notice.
2.4 Termination for Cause. Either Party may terminate this Agreement immediately
upon written notice if the other Party: (a) materially breaches this Agreement and
fails to cure such breach within ten (10) business days of receiving written notice
thereof; (b) becomes insolvent or makes a general assignment for the benefit of
creditors; or (c) has its business license revoked or suspended.
─────────────────────────────────────────────────────────────────────────────────
3. COMPENSATION
─────────────────────────────────────────────────────────────────────────────────
3.1 Fees. In consideration for the services provided hereunder, Client shall pay
Contractor in accordance with the rate schedule set forth in Exhibit A, attached
hereto and incorporated by reference.
3.2 Invoicing. Contractor shall submit invoices to Client on a [WEEKLY / BI-WEEKLY /
MONTHLY] basis. Each invoice shall include a description of services performed, dates,
mileage logs, and any applicable fuel surcharges.
3.3 Payment Terms. Client shall pay all undisputed invoices within fifteen (15) days
of receipt. Invoices not paid within [30] days of the due date shall accrue interest
at the rate of [1.5%] per month (or the maximum rate permitted by law, whichever is
less).
3.4 Expenses. Unless otherwise specified in Exhibit A, Contractor shall be
responsible for all operating expenses, including fuel, vehicle maintenance, insurance
premiums, and licensing fees.
─────────────────────────────────────────────────────────────────────────────────
4. INDEPENDENT CONTRACTOR STATUS
─────────────────────────────────────────────────────────────────────────────────
4.1 The Parties acknowledge and agree that Contractor is an independent contractor
and not an employee, agent, partner, or joint venturer of Client. Contractor shall
have sole control over the manner and means by which the services are performed,
subject to the requirements of this Agreement.
4.2 Contractor shall be responsible for all federal, state, and local taxes,
including self-employment taxes, arising from compensation paid under this Agreement.
Client shall not withhold any taxes from payments to Contractor. Client shall issue
IRS Form 1099-NEC to Contractor as required by applicable law.
4.3 Contractor's employees or subcontractors, if any, are solely the employees or
contractors of Contractor, and Contractor assumes full and sole responsibility for
their acts and omissions, compensation, benefits, and compliance with applicable
employment laws.
─────────────────────────────────────────────────────────────────────────────────
5. HIPAA COMPLIANCE
─────────────────────────────────────────────────────────────────────────────────
5.1 The Parties acknowledge that Contractor may have access to Protected Health
Information ("PHI") as defined under the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") and its implementing regulations.
5.2 The Parties agree to execute a Business Associate Agreement ("BAA"), attached
hereto as Exhibit B, which sets forth each Party's obligations with respect to PHI.
5.3 Contractor shall implement and maintain appropriate administrative, physical, and
technical safeguards to protect the confidentiality, integrity, and availability of
any PHI to which it has access in connection with its performance of services under
this Agreement.
─────────────────────────────────────────────────────────────────────────────────
6. INSURANCE REQUIREMENTS
─────────────────────────────────────────────────────────────────────────────────
6.1 Contractor shall obtain and maintain, at its own expense, the following insurance
coverages throughout the term of this Agreement:
(a) Commercial Automobile Liability Insurance: minimum limits of $1,000,000
combined single limit per occurrence for bodily injury and property damage,
covering all owned, hired, and non-owned vehicles used in connection with
the services.
(b) Commercial General Liability Insurance: minimum limits of $1,000,000 per
occurrence and $2,000,000 in the aggregate, covering bodily injury, property
damage, and personal and advertising injury.
(c) Cargo / Motor Truck Cargo Insurance: minimum limits of $[CARGO LIMIT, e.g.,
100,000] per occurrence, covering loss or damage to client's materials in
Contractor's custody.
(d) Workers' Compensation Insurance: as required by the laws of the State of
[YOUR STATE], and Employer's Liability Insurance with limits of not less than
$[LIMIT] per occurrence.
6.2 Contractor shall name Client as an additional insured on its commercial
automobile and general liability policies. Upon request, Contractor shall provide
Client with certificates of insurance evidencing the required coverages.
─────────────────────────────────────────────────────────────────────────────────
7. CHAIN OF CUSTODY
─────────────────────────────────────────────────────────────────────────────────
7.1 Contractor shall maintain a documented chain of custody for all specimens and
sensitive materials transported under this Agreement, recording at minimum: (a) item
description and unique identifier or label; (b) pickup date, time, and location;
(c) name and signature of individual releasing the item to Contractor; (d) delivery
date, time, and location; and (e) name and signature of individual receiving the item.
7.2 Contractor shall make chain of custody records available to Client upon request,
and shall retain such records for a minimum of [RETENTION PERIOD, e.g., three (3)
years] following the date of service.
─────────────────────────────────────────────────────────────────────────────────
8. LIABILITY AND INDEMNIFICATION
─────────────────────────────────────────────────────────────────────────────────
8.1 Contractor shall indemnify, defend, and hold harmless Client and its officers,
directors, employees, and agents from and against any claims, damages, losses, costs,
and expenses (including reasonable attorneys' fees) arising out of or relating to: (a)
Contractor's negligence or willful misconduct in the performance of services; (b) any
breach of this Agreement by Contractor; or (c) any violation of applicable law by
Contractor.
8.2 Client shall indemnify, defend, and hold harmless Contractor from and against
any claims arising out of or relating to Client's negligence or willful misconduct,
or Client's breach of this Agreement.
8.3 IN NO EVENT SHALL EITHER PARTY BE LIABLE TO THE OTHER FOR ANY INDIRECT,
INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, REGARDLESS OF THE FORM
OF ACTION OR THE BASIS OF THE CLAIM, EVEN IF SUCH PARTY HAS BEEN ADVISED OF THE
POSSIBILITY OF SUCH DAMAGES. CONTRACTOR'S TOTAL CUMULATIVE LIABILITY ARISING OUT OF
OR RELATED TO THIS AGREEMENT SHALL NOT EXCEED THE TOTAL FEES PAID BY CLIENT TO
CONTRACTOR IN THE THREE (3) MONTHS PRECEDING THE CLAIM.
─────────────────────────────────────────────────────────────────────────────────
9. CONFIDENTIALITY
─────────────────────────────────────────────────────────────────────────────────
9.1 Each Party agrees to maintain the confidentiality of the other Party's
Confidential Information and not to disclose such information to any third party
without prior written consent, except as required by law or as necessary to perform
obligations under this Agreement. "Confidential Information" means any non-public
business, technical, financial, or operational information disclosed by one Party to
the other.
9.2 Contractor shall not use Client's name, logo, or any information about Client's
operations for marketing or promotional purposes without Client's prior written
consent.
─────────────────────────────────────────────────────────────────────────────────
10. GOVERNING LAW AND DISPUTE RESOLUTION
─────────────────────────────────────────────────────────────────────────────────
10.1 This Agreement shall be governed by and construed in accordance with the laws
of the State of [YOUR STATE], without regard to conflict of law principles.
10.2 Any dispute arising out of or relating to this Agreement that the Parties are
unable to resolve through good-faith negotiation within thirty (30) days shall be
submitted to binding arbitration in [CITY, STATE] under the rules of the American
Arbitration Association, before a single arbitrator. The prevailing party shall be
entitled to recover reasonable attorneys' fees and costs.
─────────────────────────────────────────────────────────────────────────────────
11. GENERAL PROVISIONS
─────────────────────────────────────────────────────────────────────────────────
11.1 Entire Agreement. This Agreement, together with all exhibits attached hereto,
constitutes the entire agreement between the Parties with respect to its subject
matter and supersedes all prior negotiations, representations, warranties, and
understandings.
11.2 Amendment. This Agreement may not be amended or modified except by a written
instrument signed by authorized representatives of both Parties.
11.3 Waiver. The failure of either Party to enforce any provision of this Agreement
shall not constitute a waiver of that Party's right to enforce such provision
thereafter.
11.4 Severability. If any provision of this Agreement is held invalid or
unenforceable, the remaining provisions shall remain in full force and effect.
11.5 Notices. All notices shall be in writing and delivered by email (with
confirmation of receipt), certified mail, or overnight courier to the addresses set
forth above.
11.6 Counterparts. This Agreement may be executed in counterparts, each of which
shall constitute an original, and electronic signatures shall be deemed valid.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.
CONTRACTOR: CLIENT:
[YOUR BUSINESS NAME] [CLIENT FACILITY NAME]
Signature: ___________________________ Signature: ___________________________
Printed Name: ________________________ Printed Name: ________________________
Title: _______________________________ Title: _______________________________
Date: ________________________________ Date: ________________________________
═══════════════════════════════════════════════════════════════════════════════════
EXHIBIT A — RATE SCHEDULE
(See Template 3: Rate Sheet / Capability Statement)
═══════════════════════════════════════════════════════════════════════════════════
EXHIBIT B — HIPAA BUSINESS ASSOCIATE AGREEMENT
(See Template 2: HIPAA BAA)
═══════════════════════════════════════════════════════════════════════════════════
Template 2 of 4
HIPAA Business Associate Agreement (BAA)
HIPAA BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement ("BAA" or "Agreement") is entered into as of
[EFFECTIVE DATE] and is incorporated into the Independent Contractor Service
Agreement between [CLIENT FACILITY NAME] ("Covered Entity") and [YOUR BUSINESS NAME]
("Business Associate"). This BAA supplements and is made part of the Service
Agreement.
─────────────────────────────────────────────────────────────────────────────────
1. DEFINITIONS
─────────────────────────────────────────────────────────────────────────────────
Capitalized terms used but not defined in this BAA have the meanings ascribed to
them in the HIPAA Rules.
"HIPAA Rules" means the Privacy, Security, Breach Notification, and Enforcement
Rules at 45 C.F.R. Parts 160 and 164.
"Protected Health Information" or "PHI" has the meaning set forth in 45 C.F.R.
§ 160.103, limited to the PHI Business Associate creates, receives, maintains, or
transmits on behalf of Covered Entity in connection with the services.
"Breach" has the meaning set forth in 45 C.F.R. § 164.402.
"Subcontractor" means a person who acts on behalf of Business Associate and handles
PHI.
─────────────────────────────────────────────────────────────────────────────────
2. OBLIGATIONS OF BUSINESS ASSOCIATE
─────────────────────────────────────────────────────────────────────────────────
2.1 Permitted Uses and Disclosures. Business Associate shall not use or disclose PHI
other than as permitted or required by this BAA, the Service Agreement, or as
required by applicable law. Business Associate may use or disclose PHI:
(a) as necessary to perform the transportation and courier services under the
Service Agreement;
(b) as required by law; or
(c) for the proper management and administration of Business Associate's
business, provided that disclosures are required by law or Business Associate
obtains written assurances from the recipient to maintain the confidentiality
of the information and to notify Business Associate of any known breaches.
2.2 Safeguards. Business Associate shall use appropriate administrative, physical,
and technical safeguards, and comply with Subpart C of 45 C.F.R. Part 164 with
respect to electronic PHI, to prevent use or disclosure of PHI other than as
provided for by this BAA.
2.3 Reporting.
(a) Business Associate shall report to Covered Entity any use or disclosure of
PHI not permitted by this BAA without unreasonable delay and in no event
later than [REPORTING PERIOD, e.g., ten (10) business days] after discovery.
(b) Business Associate shall report to Covered Entity any Security Incident (as
defined in 45 C.F.R. § 164.304) of which it becomes aware, in accordance
with the timeframes set forth above.
(c) Business Associate shall notify Covered Entity of any Breach of Unsecured
PHI without unreasonable delay and in no event later than sixty (60) calendar
days after discovery of the Breach. Notification shall include, to the extent
possible, the identification of each individual whose PHI was involved and
other information required under 45 C.F.R. § 164.410.
2.4 Subcontractors. Business Associate shall ensure that any Subcontractors that
create, receive, maintain, or transmit PHI on behalf of Business Associate agree to
the same restrictions, conditions, and requirements that apply to Business Associate
under this BAA. Business Associate shall maintain a copy of each such agreement and
make it available to Covered Entity upon request.
2.5 Access to PHI. Business Associate shall make PHI in a Designated Record Set
available to Covered Entity within fifteen (15) days of a request, to permit Covered
Entity to fulfill its obligations under 45 C.F.R. § 164.524.
2.6 Amendment. Business Associate shall make available PHI in a Designated Record
Set for amendment and shall incorporate any amendments to PHI in accordance with 45
C.F.R. § 164.526 upon request by Covered Entity.
2.7 Accounting of Disclosures. Business Associate shall document and make available
information required for Covered Entity to provide an accounting of disclosures of
PHI in accordance with 45 C.F.R. § 164.528.
2.8 HHS Inspection. Business Associate shall make its internal practices, books, and
records relating to the use and disclosure of PHI available to the Secretary of HHS
for purposes of determining Covered Entity's compliance with the HIPAA Rules.
─────────────────────────────────────────────────────────────────────────────────
3. OBLIGATIONS OF COVERED ENTITY
─────────────────────────────────────────────────────────────────────────────────
3.1 Covered Entity shall notify Business Associate of any limitation in its Notice
of Privacy Practices to the extent such limitation may affect Business Associate's
use or disclosure of PHI.
3.2 Covered Entity shall notify Business Associate of any changes in, or revocation
of, permission by an individual to use or disclose PHI, to the extent that such
changes may affect Business Associate's permitted or required uses and disclosures.
3.3 Covered Entity shall not request Business Associate to use or disclose PHI in
any manner that would not be permissible under the HIPAA Rules if done by Covered
Entity directly.
─────────────────────────────────────────────────────────────────────────────────
4. TERM AND TERMINATION
─────────────────────────────────────────────────────────────────────────────────
4.1 Term. This BAA is effective as of the Effective Date and shall remain in effect
until termination of the Service Agreement, unless earlier terminated as provided
herein.
4.2 Termination for Cause. If either Party determines that the other Party has
materially breached a material term of this BAA and such breach is not cured within
thirty (30) days of written notice, the non-breaching Party may immediately terminate
this BAA and the Service Agreement.
4.3 Effect of Termination; Return or Destruction of PHI. Upon termination of this
BAA for any reason, Business Associate shall, at the direction of Covered Entity,
either return or destroy all PHI that Business Associate still maintains in any form.
Business Associate shall not retain copies of PHI after return or destruction.
If Business Associate determines that return or destruction is infeasible, Business
Associate shall notify Covered Entity and extend the protections of this BAA to such
PHI and limit further uses and disclosures to those purposes that make return or
destruction infeasible, for as long as Business Associate maintains such PHI.
─────────────────────────────────────────────────────────────────────────────────
5. GENERAL PROVISIONS
─────────────────────────────────────────────────────────────────────────────────
5.1 Interpretation. This BAA shall be interpreted in a manner consistent with the
HIPAA Rules. Any ambiguity shall be resolved in favor of a meaning that permits
Covered Entity to comply with the HIPAA Rules.
5.2 Regulatory References. A reference to a section in the HIPAA Rules means the
section then in effect, as amended.
5.3 Survival. Business Associate's obligations with respect to the return or
destruction of PHI and any reporting obligations survive termination of this BAA.
5.4 No Third-Party Beneficiaries. Nothing in this BAA is intended to confer any
rights, remedies, obligations, or liabilities upon any person other than the Parties.
COVERED ENTITY: BUSINESS ASSOCIATE:
[CLIENT FACILITY NAME] [YOUR BUSINESS NAME]
Signature: ___________________________ Signature: ___________________________
Printed Name: ________________________ Printed Name: ________________________
Title: _______________________________ Title: _______________________________
Date: ________________________________ Date: ________________________________
Template 3 of 4
Rate Sheet / Capability Statement
════════════════════════════════════════════════════════════════════════════════
[YOUR BUSINESS NAME]
MEDICAL COURIER SERVICES
CAPABILITY STATEMENT & RATE SCHEDULE
════════════════════════════════════════════════════════════════════════════════
PREPARED FOR: [CLIENT FACILITY NAME / "General Distribution"]
PREPARED BY: [YOUR NAME], Owner / Operator
DATE: [DATE]
VALID THROUGH: [EXPIRATION DATE, e.g., 90 days from above]
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
ABOUT [YOUR BUSINESS NAME]
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
[YOUR BUSINESS NAME] is a [STATE]-based independent medical courier providing
reliable, compliant specimen and medical supply transport for healthcare facilities,
clinical laboratories, physician offices, and specialty clinics.
Business Structure: [LLC / Sole Proprietorship]
Owner / Operator: [YOUR NAME]
Phone: [YOUR PHONE NUMBER]
Email: [YOUR EMAIL ADDRESS]
Address: [YOUR BUSINESS ADDRESS]
USDOT #: [DOT NUMBER, if applicable]
MC #: [MOTOR CARRIER NUMBER, if applicable]
Business License #: [LICENSE NUMBER]
Tax ID (EIN): [EIN or SSN-LAST-4]
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
SERVICES OFFERED
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
✦ SCHEDULED ROUTES
Daily or recurring fixed-route pickup and delivery between your facilities,
reference labs, and satellite clinics. Consistent driver, consistent timing.
✦ STAT RUNS
On-demand, priority transport for time-critical specimens and materials.
Target response time: [YOUR RESPONSE TIME, e.g., 30–45 minutes].
Available: [AVAILABILITY HOURS, e.g., Mon–Fri 6 AM–8 PM].
✦ SAME-DAY DELIVERY
Flexible same-day pickup and delivery for non-urgent materials including
medical records, supplies, equipment, and pharmaceuticals.
✦ LAST-MILE FULFILLMENT
Final-leg delivery from distribution centers, pharmacies, or laboratories
to clinic locations, assisted living facilities, and patient homes
(where applicable and permitted by law).
✦ SPECIALTY TRANSPORT
Temperature-sensitive specimens (ambient / refrigerated / frozen) using
validated transport packaging. Dry ice and cold-pack capability available.
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COVERAGE AREA
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Primary Service Area: [CITY / COUNTY / METRO AREA]
Extended Coverage: [SURROUNDING COUNTIES OR CITIES]
Maximum Radius: Approximately [XX] miles from [HOME BASE CITY]
Out-of-area routes considered on a case-by-case basis. Contact us for a
custom quote.
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
RATE STRUCTURE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
All rates are exclusive of applicable taxes and fuel surcharges.
Volume discounts available for committed monthly route contracts.
┌─────────────────────────────────────────┬────────────────────────────────┐
│ SERVICE TYPE │ RATE │
├─────────────────────────────────────────┼────────────────────────────────┤
│ Per-Mile Rate (standard) │ $[X.XX] per mile │
│ Per-Run (local, under [XX] miles) │ $[XX.XX] flat per run │
│ STAT / Priority Run │ $[XX.XX] flat + $[X.XX]/mile │
│ Scheduled Daily Route (per day) │ $[XX.XX] per day │
│ Monthly Route Contract (flat rate) │ $[XXX.XX] per month │
│ After-Hours / Weekend Premium │ $[XX.XX] additional per run │
│ Dry Ice / Temperature Pack (per trip) │ $[X.XX]–$[X.XX] │
│ Wait Time (beyond 10 min at pickup) │ $[XX.XX] per 15 min │
└─────────────────────────────────────────┴────────────────────────────────┘
Fuel Surcharge: Applied when average local diesel/gasoline price exceeds
$[TRIGGER PRICE] per gallon. Surcharge = [XX]% of base run rate.
Mileage is calculated from [YOUR HOME BASE / FIRST PICKUP LOCATION] to the
final drop-off location via the most direct navigable route.
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
INSURANCE & COMPLIANCE CREDENTIALS
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Commercial Auto Liability: $1,000,000 CSL — [INSURER NAME]
Policy #: [POLICY NUMBER]
General Liability: $1,000,000 / $2,000,000 aggregate
Policy #: [POLICY NUMBER]
Cargo Insurance: $[CARGO LIMIT]
Policy #: [POLICY NUMBER]
HIPAA Compliance: Trained and compliant; BAA available upon request
OSHA Bloodborne Pathogen: Certified — [CERTIFICATION DATE]
DOT / Hazmat Awareness: [CERTIFICATION NAME, if applicable]
Chain of Custody: Documented for all specimen transport
Certificates of insurance naming your facility as additional insured
available upon request within 48 hours.
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
CONTACT & NEXT STEPS
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
To get started, request a certificate of insurance, or discuss a custom
route proposal, please contact:
[YOUR NAME]
[YOUR BUSINESS NAME]
Phone: [YOUR PHONE NUMBER]
Email: [YOUR EMAIL ADDRESS]
Website: [YOUR WEBSITE, if applicable]
We look forward to serving [CLIENT FACILITY NAME] with reliable, professional
medical courier services.
════════════════════════════════════════════════════════════════════════════════
Rates subject to change with 30 days' written notice. This document does not
constitute a binding contract. Services governed by a fully executed Independent
Contractor Service Agreement.
════════════════════════════════════════════════════════════════════════════════
Template 4 of 4
Service Invoice
════════════════════════════════════════════════════════════════════════════════
[YOUR BUSINESS NAME]
MEDICAL COURIER SERVICES
════════════════════════════════════════════════════════════════════════════════
S E R V I C E I N V O I C E
Invoice #: INV-[YYYYMM]-[SEQUENTIAL NUMBER, e.g., 0042]
Invoice Date: [DATE]
Service Period: [START DATE] – [END DATE]
Due Date: [DATE + 15 DAYS] (Net 15)
────────────────────────────────────────────────────────────────────────────────
FROM BILL TO
────────────────────────────────────────────────────────────────────────────────
[YOUR BUSINESS NAME] [CLIENT FACILITY NAME]
[YOUR NAME], Owner Attn: [ACCOUNTS PAYABLE CONTACT]
[YOUR ADDRESS LINE 1] [CLIENT ADDRESS LINE 1]
[YOUR CITY, STATE ZIP] [CLIENT CITY, STATE ZIP]
[YOUR PHONE] [CLIENT PHONE]
[YOUR EMAIL] [CLIENT AP EMAIL]
EIN: [YOUR EIN]
────────────────────────────────────────────────────────────────────────────────
SERVICES RENDERED
┌──────────────┬──────────────────────────────────┬────────────┬──────────┬────────────┐
│ DATE │ SERVICE DESCRIPTION │ MI/UNITS │ RATE │ TOTAL │
├──────────────┼──────────────────────────────────┼────────────┼──────────┼────────────┤
│ [MM/DD] │ Scheduled Route — [ROUTE NAME] │ [XX] mi │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ Scheduled Route — [ROUTE NAME] │ [XX] mi │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ STAT Run — [PICKUP → DROP-OFF] │ [XX] mi │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ STAT Run — [PICKUP → DROP-OFF] │ [XX] mi │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ Same-Day Delivery — [DETAILS] │ [XX] mi │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ After-Hours Premium │ 1 run │ $[X.XX] │ $[XX.XX] │
│ [MM/DD] │ Temperature Pack — Specimen │ 1 trip │ $[X.XX] │ $[XX.XX] │
│ │ [ADD ROWS AS NEEDED] │ │ │ │
└──────────────┴──────────────────────────────────┴────────────┴──────────┴────────────┘
────────────────────────────────────────────────────────────────────────────────
SUBTOTAL $[XXX.XX]
Fuel Surcharge ([X]% — avg. $[X.XX]/gal this period) $[XX.XX]
─────────────
GRAND TOTAL DUE $[XXX.XX]
────────────────────────────────────────────────────────────────────────────────
PAYMENT TERMS
Payment is due within fifteen (15) days of invoice date (Net 15).
Due Date: [DUE DATE]
Late payments are subject to a monthly finance charge of 1.5% (or the
maximum rate permitted by applicable law).
PAYMENT METHODS
☐ Check payable to: [YOUR BUSINESS NAME]
Mail to: [YOUR MAILING ADDRESS]
☐ ACH / Bank Transfer:
Bank: [BANK NAME]
Routing #: [ROUTING NUMBER]
Account #: [ACCOUNT NUMBER]
Account Name: [YOUR BUSINESS NAME]
☐ Zelle / Venmo: [YOUR PHONE OR EMAIL LINKED TO ACCOUNT]
☐ Other: [E.G., BILL.COM LINK OR OTHER PAYMENT PORTAL]
Please reference Invoice # INV-[YYYYMM]-[NNNN] with your payment.
────────────────────────────────────────────────────────────────────────────────
Questions about this invoice? Contact [YOUR NAME] at [YOUR PHONE] or
[YOUR EMAIL]. We're happy to provide a detailed mileage log or chain of
custody records for any run listed above upon request.
Thank you for trusting [YOUR BUSINESS NAME] with your courier needs.
We appreciate your business and look forward to continuing to serve
[CLIENT FACILITY NAME].
════════════════════════════════════════════════════════════════════════════════
[YOUR BUSINESS NAME] · [YOUR PHONE] · [YOUR EMAIL]
[YOUR WEBSITE, if applicable]
════════════════════════════════════════════════════════════════════════════════