Purchase Order Psychiatrist in United States Houston –Free Word Template Download with AI
Memorial Hermann Health System – Behavioral Health Division
1102 Saint Joseph Pkwy, Houston, Texas 77031, United States
Phone: (713) 790-1000 | Fax: (713) 790-1001 | Email: [email protected]
Tax ID (EIN): 74-1234567 | NPI: 1234567890
VENDOR / SERVICE PROVIDER INFORMATION| Field | Details |
|---|---|
| Provider Name: | Dr. Marcus T. Whitfield, MD, FAAP – Board-Certified Psychiatrist |
| Practice Name: | Whitfield Behavioral Medicine Associates, PLLC |
| Address: | 2200 Post Oak Blvd, Suite 1450, Houston, Texas 77056, United States |
| License Number: | TX Medical License #M-2847193 (Texas Medical Board) |
| NPI Number: | 1497823651 |
| Specialty: | Adult & Adolescent Psychiatry, Psychopharmacology, Neuropsychiatry |
| Contact: | Dr. Whitfield | (713) 555-0192 | [email protected] |
| Bank / Payment Info: | First National Bank of Houston – ABA: 121000358 – Account: ****6721 |
| Item # | Description of Psychiatrist Services | CPT Code | Qty | Unit Rate (USD) | Extended Amount (USD) |
|---|---|---|---|---|---|
| 1 | Initial comprehensive psychiatric evaluation and diagnostic assessment for referred patients (90-minute session), to be conducted at the Houston, Texas outpatient facility | 99205 | 40 | $385.00 | $15,400.00 |
| 2 | Follow-up psychiatric consultation and medication management session (45-minute session) for ongoing patient care in the Houston metropolitan area | 99214 | 120 | $245.00 | $29,400.00 |
| 3 | Psychiatric crisis intervention and emergency consultation services (on-call availability, 24/7 coverage for the Houston, United States service region) | 99215 | 25 | $425.00 | $10,625.00 |
| 4 | Psychopharmacological treatment planning, including prescription authorization, therapeutic drug monitoring coordination, and quarterly treatment progress reports | 90837 | 60 | $195.00 | $11,700.00 |
| 5 | Interdisciplinary case conference participation and peer-to-peer psychiatric consultation with the Behavioral Health Division team in Houston, Texas | 99241 | 12 | $175.00 | $2,100.00 |
| 6 | Annual competency review, malpractice insurance verification, and credentialing documentation maintenance for the Psychiatrist provider | — | 1 | $1,200.00 | $1,200.00 |
| SUBTOTAL | $70,425.00 | ||||
| Applicable Texas Sales Tax (0% – Professional Medical Services Exempt) | $0.00 | ||||
| TOTAL PURCHASE ORDER AMOUNT (USD) | $70,425.00 | ||||
- Scope of Services: This Purchase Order authorizes the contracted Psychiatrist, Dr. Marcus T. Whitfield, to provide the psychiatric services enumerated above to patients referred by Memorial Hermann Health System's Behavioral Health Division. All services shall be rendered in compliance with the Texas Medical Practice Act and applicable federal regulations within the Houston, United States service area.
- Payment Terms: Net 30 days from receipt of an accurate and undisputed invoice. Payment shall be processed via electronic funds transfer (EFT) to the bank account specified in the Vendor Information section. Late payments shall accrue interest at 1.5% per month as permitted under Texas Business & Commerce Code §271.101.
- Service Location: All in-person psychiatric consultations, evaluations, and follow-up appointments shall take place at the designated outpatient facility located in Houston, Texas 77056, United States, or at such other location within the Houston metropolitan area as mutually agreed upon in writing by both parties.
- Compliance and Licensure: The Psychiatrist shall maintain an active, unrestricted license to practice medicine in the State of Texas, valid DEA registration for controlled substance prescribing, and malpractice insurance with a minimum coverage of $2,000,000 per occurrence. Proof of licensure and insurance shall be provided upon request and renewed annually.
- Confidentiality: All patient information shall be handled in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA), the Texas Medical Records Act, and the facility's internal data protection policies. A Business Associate Agreement (BAA) is attached as Exhibit A to this Purchase Order.
- Performance Standards: The Psychiatrist shall maintain a patient no-show rate below 15%, respond to urgent consultation requests within four (4) business hours, and submit all required clinical documentation within 48 hours of each patient encounter. Failure to meet these standards for two consecutive billing cycles may result in termination of this Purchase Order with 30 days' written notice.
- Termination: Either party may terminate this Purchase Order with thirty (30) days' written notice. In the event of termination, the Psychiatrist shall complete all in-progress patient care plans and provide a comprehensive transition summary to the receiving provider within the Houston, United States network.
- Governing Law: This Purchase Order shall be governed by and construed in accordance with the laws of the State of Texas, United States. Any disputes arising hereunder shall be resolved through binding arbitration in Harris County, Houston, Texas, in accordance with the Texas Arbitration Act.
- Force Majeure: Neither party shall be liable for failure to perform obligations under this Purchase Order due to events beyond reasonable control, including but not limited to natural disasters affecting the Houston, Texas region, acts of government, or public health emergencies declared by the United States federal government.
- Entire Agreement: This Purchase Order, together with its attached exhibits, constitutes the entire agreement between the parties regarding the procurement of Psychiatrist services and supersedes all prior negotiations, representations, or agreements, whether oral or written.
For Memorial Hermann Health System (Buyer):
Dr. Angela Reeves, MD – Chief of Behavioral Health
Date: ______________________
James O. Patterson – Director of Procurement
Date: ______________________
For Whitfield Behavioral Medicine Associates (Provider):
Dr. Marcus T. Whitfield, MD, FAAP – Psychiatrist / Principal
Date: ______________________
Sarah L. Chen – Practice Administrator
Date: ______________________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT