Purchase Order Ophthalmologist in United States San Francisco –Free Word Template Download with AI
Bay Area Vision Care Group, LLC
1200 Market Street, Suite 450, San Francisco, California 94102, United States
Phone: (415) 555-0187 | Email: [email protected]
California Business License No. 12345678-90 | EIN: 94-XXXXXXX
Dr. Elena M. Vasquez, M.D., F.A.C.S.
Board-Certified Ophthalmologist – Golden Gate Eye & Vision Institute
2847 Fillmore Street, Suite 310, San Francisco, California 94115, United States
License No.: CA-OPH-2019-44782 | DEA Registration: FW4829103
Phone: (415) 555-0342 | Fax: (415) 555-0343 | Email: [email protected]
Bay Area Vision Care Group, LLC – Procurement Department
1200 Market Street, Suite 450, San Francisco, California 94102, United States
Attn: Mr. David R. Thornton, Director of Procurement
| # | Description | Qty | Unit Price (USD) | Extended Price (USD) | Delivery / Service Date |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation and Diagnostic Eye Examination – including OCT, visual field testing, and anterior segment evaluation for 120 patient appointments | 120 | $285.00 | $34,200.00 | July 1 – August 15, 2025 |
| 2 | Cataract Surgery (Phacoemulsification with IOL Implantation) – performed by the Ophthalmologist at Golden Gate Eye & Vision Institute, San Francisco, CA | 24 | $4,850.00 | $116,400.00 | July 10 – September 30, 2025 |
| 3 | Retinal Laser Photocoagulation Treatment – administered by the Ophthalmologist for diabetic retinopathy management | 36 | $1,200.00 | $43,200.00 | July 15 – October 15, 2025 |
| 4 | Custom Prescription Ophthalmic Lenses and Frame Fittings – dispensed under the Ophthalmologist's prescription at the San Francisco clinic | 200 | $185.00 | $37,000.00 | August 1 – September 30, 2025 |
| 5 | Post-Operative Follow-Up Visits with the Ophthalmologist – includes wound check, IOP measurement, and visual acuity assessment (3 visits per surgical patient) | 72 | $150.00 | $10,800.00 | July 20 – November 30, 2025 |
| 6 | Specialized Ophthalmic Equipment Rental – Topcon iOpulu OCT and Zeiss Visumax 800 femtosecond laser, available at the Ophthalmologist's San Francisco facility | 1 | $12,500.00 | $12,500.00 | July 1 – December 31, 2025 |
| 7 | Pharmacological Supplies – topical anesthetics, antibiotic drops, and anti-inflammatory medications prescribed by the Ophthalmologist for post-procedure care | 1 | $8,750.00 | $8,750.00 | July 1 – November 30, 2025 |
| SUBTOTAL | $262,850.00 | ||||
| California Sales Tax (8.5%) | $22,342.25 | ||||
| TOTAL AMOUNT DUE (USD) | $285,192.25 | ||||
- This Purchase Order is issued by Bay Area Vision Care Group, LLC, a California-registered entity operating in San Francisco, United States, and constitutes a binding agreement upon acceptance by the Ophthalmologist, Dr. Elena M. Vasquez, and the Golden Gate Eye & Vision Institute.
- All ophthalmological services referenced in this Purchase Order shall be performed by the named Ophthalmologist or, in the event of documented unavailability, by a board-certified Ophthalmologist of equivalent or greater experience at the same San Francisco, California facility. Substitution requires prior written approval from the Procurement Director.
- Payment shall be remitted within thirty (30) calendar days of receipt of a valid invoice. Payment shall be made via ACH transfer to the bank account designated by the Ophthalmologist's practice in San Francisco, United States. Late payments shall accrue interest at 1.5% per month as permitted under California Civil Code Section 3289.
- All medical services and procedures shall comply with the standards set forth by the California Medical Board, the American Academy of Ophthalmology, and applicable federal regulations of the United States Department of Health and Human Services. The Ophthalmologist warrants that all procedures will be performed in accordance with the standard of care expected of a licensed Ophthalmologist practicing in the State of California.
- Delivery of all physical goods, including ophthalmic lenses, frames, and pharmacological supplies, shall be made to the receiving address in San Francisco, California 94102, United States. The vendor assumes full risk of loss until goods are received and inspected at the designated San Francisco location.
- The Ophthalmologist shall maintain current malpractice liability insurance with a minimum coverage of $5,000,000 per occurrence and $10,000,000 aggregate, naming Bay Area Vision Care Group, LLC as an additional insured. A certificate of insurance shall be provided prior to the commencement of services.
- Confidentiality: All patient health information obtained in connection with this Purchase Order shall be handled in strict compliance with the Health Insurance Portability and Accountability Act (HIPAA) of the United States and the California Confidentiality of Medical Information Act (CMIA), Civil Code Section 56 et seq.
- This Purchase Order is governed by the laws of the State of California and the federal laws of the United States. Any disputes arising hereunder shall be resolved through binding arbitration in San Francisco, California, in accordance with the rules of the American Arbitration Association.
- Either party may terminate this Purchase Order with thirty (30) days written notice. In the event of termination, the Ophthalmologist shall complete all scheduled procedures already in progress and provide full clinical documentation to the patient's record.
- All prices quoted in this Purchase Order are fixed for the duration of the contract period and are denominated in United States Dollars (USD). No price adjustments shall be made without mutual written consent.
For Bay Area Vision Care Group, LLC (Buyer):
David R. Thornton, Director of Procurement
Date: ____________________
For Golden Gate Eye & Vision Institute (Ophthalmologist / Vendor):
Dr. Elena M. Vasquez, M.D., F.A.C.S.
Board-Certified Ophthalmologist, San Francisco, CA
Date: ____________________
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