Purchase Order Psychiatrist in Israel Tel Aviv –Free Word Template Download with AI
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Mental Health Services Procurement Division Tel Aviv Medical Group Ltd. 125 Ben-Gurion Avenue, Tel Aviv, Israel 6310000 Tel: +972-3-620-4500 | Email: [email protected] |
Purchase Order No.: PO-2025-TLV-04872 Date of Issue: 14 June 2025 Valid Until: 14 September 2025 Payment Terms: Net 30 Days Currency: Israeli New Shekel (ILS) |
| Provider Name: | Dr. Miriam Levi, M.D., Board-Certified Psychiatrist |
| Practice Name: | Levi Psychiatric & Behavioral Health Clinic |
| Address: | 48 Rothschild Boulevard, Suite 312, Tel Aviv, Israel 6511801 |
| License No.: | IL-PSY-2019-00482 (Issued by the Israeli Medical Council, Tel Aviv District) |
| VAT Number: | 51-804-221-77 |
| Contact: | +972-3-517-8890 | [email protected] |
| Department: | Corporate Wellness & Employee Assistance Program (EAP) |
| Facility: | Tel Aviv Medical Group – Central Campus, Tel Aviv, Israel |
| Authorized By: | Mr. David Cohen, Director of Human Resources |
| Cost Center: | CC-7741-EAP-PSY |
| Item # | Description of Psychiatrist Service | Qty | Unit Price (ILS) | Total (ILS) |
|---|---|---|---|---|
| 001 | Initial psychiatric evaluation and diagnostic consultation – 60 minutes per session, conducted by a licensed Psychiatrist at the Tel Aviv practice location | 24 | 1,200.00 | 28,800.00 |
| 002 | Follow-up psychiatric therapy sessions – 45 minutes per session, ongoing treatment plan management by the assigned Psychiatrist | 96 | 950.00 | 91,200.00 |
| 003 | Psychiatric medication management and prescription review – 30 minutes per session, including coordination with the patient's primary care physician in Israel Tel Aviv | 48 | 700.00 | 33,600.00 |
| 004 | Crisis intervention and emergency psychiatric consultation – available 24/7 via telehealth or in-person at the Tel Aviv clinic, per incident | 12 | 2,500.00 | 30,000.00 |
| 005 | Group psychiatric wellness workshops for corporate employees – 2-hour facilitated sessions led by the Psychiatrist, held at the Tel Aviv Medical Group headquarters | 8 | 3,200.00 | 25,600.00 |
| 006 | Comprehensive psychiatric assessment report and treatment documentation – written report in English and Hebrew, filed with the employee's confidential medical record | 24 | 450.00 | 10,800.00 |
| SUBTOTAL | 220,000.00 | |||
| VAT 18%: 39,600.00 | ||||
| GRAND TOTAL (INCL. VAT) | 259,600.00 ILS | |||
- This Purchase Order constitutes a binding agreement between Tel Aviv Medical Group Ltd. (hereinafter "the Purchaser") and Dr. Miriam Levi, Psychiatrist (hereinafter "the Provider"), for the delivery of psychiatric and behavioral health services as itemized above.
- All services rendered under this Purchase Order shall be performed in full compliance with the Israeli Medical Council regulations, the National Health Insurance Law (1994), and all applicable mental health legislation governing the practice of a Psychiatrist in Israel Tel Aviv.
- The Provider warrants that the Psychiatrist named herein holds a valid, unrestricted medical license issued by the Israeli Medical Council and maintains current malpractice insurance coverage of no less than 5,000,000 ILS per claim.
- Payment shall be made within thirty (30) calendar days of receipt of a valid invoice referencing this Purchase Order number. Invoices must be submitted in ILS and include the Provider's VAT registration number. Payment shall be processed via bank transfer to the account designated by the Provider in Tel Aviv.
- All patient records, psychiatric evaluations, and treatment documentation generated under this Purchase Order are subject to the Israeli Privacy Protection Law (5741-1981) and the Medical Records Regulations. The Provider shall maintain strict confidentiality and shall not disclose any patient information to the Purchaser beyond the scope of the agreed-upon wellness program reporting.
- The Provider shall deliver all services at the practice location in Tel Aviv, Israel, or via secure telehealth platforms approved by the Israeli Ministry of Health. Any change of service location requires prior written approval from the Purchaser.
- This Purchase Order may be terminated by either party with thirty (30) days' written notice. In the event of termination, the Provider shall complete all sessions already scheduled and the Purchaser shall pay for services rendered up to the termination date.
- Any disputes arising from this Purchase Order shall be resolved through mediation in Tel Aviv, Israel, in accordance with the Israeli Arbitration Law. The governing law of this document is the law of the State of Israel.
- The Provider shall submit a quarterly summary report to the Purchaser's EAP department detailing the number of sessions conducted, aggregate utilization statistics, and any notable trends in the mental health of the employee population served in Israel Tel Aviv.
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For the Purchaser – Tel Aviv Medical Group Ltd. Signature: ___________________________ Name: David Cohen Title: Director of Human Resources Date: ___________________________ |
For the Provider – Psychiatrist Signature: ___________________________ Name: Dr. Miriam Levi, M.D. Title: Board-Certified Psychiatrist Date: ___________________________ |
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