Purchase Order Ophthalmologist in United States New York City –Free Word Template Download with AI
Formal Procurement Document for Ophthalmologist Professional Services
Jurisdiction: United States New York City, New York 10001
PO No.: NYC-OPH-2025-004872| Purchase Order Number: | NYC-OPH-2025-004872 | Date of Issue: | June 12, 2025 |
| Required Delivery/Service Date: | July 1, 2025 | Payment Terms: | Net 30 Days |
| Currency: | United States Dollar (USD) | Incoterms: | N/A (Professional Services) |
Purchasing Entity
Organization: Manhattan Comprehensive Medical Center
Department: Ophthalmology Division
Address: 450 Park Avenue South, Suite 1200, United States New York City, NY 10016
Phone: (212) 555-0147
Email: [email protected]
Tax ID (EIN): 12-3456789
Authorized Purchasing Agent
Name: Dr. Margaret L. Whitfield, MD, MBA
Title: Director of Procurement & Vendor Relations
License No.: NY-PROC-2024-8821
Phone: (212) 555-0193
Email: [email protected]
Ophthalmologist Provider
Name: Dr. James R. Callahan, MD, FACS
Specialty: Comprehensive Ophthalmologist – Retina, Glaucoma, and Cataract Surgery
Practice: Callahan Vision & Ophthalmology Associates, PLLC
Address: 285 Madison Avenue, 7th Floor, United States New York City, NY 10017
Phone: (212) 555-0382
Email: [email protected]
Licensing & Credentials
NY Medical License: 28A-4471920
Board Certification: American Board of Ophthalmology
Fellowship: American College of Surgeons (FACS)
DEA Registration: FW4829103
NYC Health Dept. Permit: HCD-OPH-2025-00341
| Item # | Description of Ophthalmologist Service / Supply | Qty | Unit | Unit Price (USD) | Extended Price (USD) |
|---|---|---|---|---|---|
| 001 | Comprehensive Ophthalmologist Consultation – Diagnostic Eye Examination (per patient session, including visual acuity testing, tonometry, and dilated fundus examination) | 120 | Sessions | $285.00 | $34,200.00 |
| 002 | Ophthalmologist Surgical Procedure – Phacoemulsification Cataract Extraction with Intraocular Lens Implantation (per procedure) | 45 | Procedures | $4,850.00 | $218,250.00 |
| 003 | Ophthalmologist Surgical Procedure – Laser-Assisted Glaucoma Treatment (SLT) (per procedure) | 30 | Procedures | $1,200.00 | $36,000.00 |
| 004 | Retinal Imaging and OCT (Optical Coherence Tomography) – Ophthalmologist Supervised Diagnostic Imaging (per scan set) | 200 | Scan Sets | $175.00 | $35,000.00 |
| 005 | Post-Operative Ophthalmologist Follow-Up Visits – Cataract and Glaucoma Recovery Monitoring (per visit) | 180 | Visits | $150.00 | $27,000.00 |
| 006 | Specialized Ophthalmologist Equipment – Portable Phacoemulsification Machine (Model: Alcon Centurion LX) – One-time procurement | 1 | Unit | $185,000.00 | $185,000.00 |
| 007 | Ophthalmologist Consumable Supplies – Intraocular Lenses (IOLs), Phaco Tips, and Surgical Kits (monthly supply contract, 6-month term) | 6 | Months | $12,500.00 | $75,000.00 |
| TOTAL PURCHASE ORDER AMOUNT (USD): | $610,450.00 | ||||
- This Purchase Order is issued by Manhattan Comprehensive Medical Center, a licensed healthcare facility operating within the United States New York City, and constitutes a binding agreement upon acceptance by the named Ophthalmologist service provider.
- All Ophthalmologist services rendered under this Purchase Order shall comply with the New York State Education Law, the New York City Health Code, and all applicable federal regulations including HIPAA (Health Insurance Portability and Accountability Act) and CMS guidelines.
- The Ophthalmologist, Dr. James R. Callahan, MD, FACS, warrants that all services and procedures listed in Section 4 shall be performed in accordance with the standard of care established by the American Academy of Ophthalmology and the American College of Surgeons.
- Payment for this Purchase Order shall be made via electronic funds transfer (EFT) to the account designated by the Ophthalmologist within thirty (30) calendar days of receipt of a valid invoice referencing Purchase Order No. NYC-OPH-2025-004872.
- The Ophthalmologist shall maintain full malpractice liability insurance with a minimum coverage of $5,000,000 per occurrence and $10,000,000 aggregate, naming Manhattan Comprehensive Medical Center as an additional insured party. Proof of insurance shall be provided prior to the commencement of services.
- All patient records, imaging data, and clinical documentation generated in connection with this Purchase Order shall be stored in compliance with New York State Public Health Law Article 27-F and the New York City Department of Health and Mental Hygiene data retention requirements.
- Any modification, amendment, or cancellation of this Purchase Order must be made in writing and signed by both the authorized purchasing agent of the Buyer and the Ophthalmologist or their designated representative.
- This Purchase Order is governed by the laws of the State of New York, and any disputes arising hereunder shall be subject to the exclusive jurisdiction of the state and federal courts located in the United States New York City, specifically the New York County (Manhattan) Supreme Court.
- The Ophthalmologist shall not subcontract any portion of the services outlined in this Purchase Order without prior written consent from the Buyer's Director of Procurement.
- Failure to meet the required service delivery dates specified in this Purchase Order may result in a penalty of 1.5% of the affected line item value per day of delay, up to a maximum of 15% of the total Purchase Order value.
By signing below, both parties acknowledge and agree to all terms, conditions, and line items specified in this Purchase Order for Ophthalmologist professional services to be delivered within the United States New York City.
For the Buyer:
Manhattan Comprehensive Medical Center
Dr. Margaret L. Whitfield, MD, MBA
Director of Procurement & Vendor Relations
Date: ______________________
For the Ophthalmologist / Seller:
Callahan Vision & Ophthalmology Associates, PLLC
Dr. James R. Callahan, MD, FACS
Principal Ophthalmologist
Date: ______________________
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