Purchase Order Psychiatrist in United States Los Angeles –Free Word Template Download with AI
9400 Wilshire Boulevard, Suite 720
Los Angeles, California 90069
United States
Tax ID (EIN): 82-4471903
Contact: Margaret Ellison, Director of Procurement
Email: [email protected] | Phone: (213) 555-0187 Dr. Jonathan R. Whitfield, M.D., F.A.P.A.
Board-Certified Psychiatrist — Private Practice
4730 Sunset Boulevard, Suite 310
Los Angeles, California 90027
United States
NPI Number: 1457892034
California Medical License: A-11847293
Contact: Dr. Jonathan Whitfield
Email: [email protected] | Phone: (323) 555-0442
This Purchase Order is issued by Westside Behavioral Health Group, LLC to formally engage the services of Dr. Jonathan R. Whitfield, a licensed Psychiatrist practicing in United States Los Angeles, for the provision of outpatient psychiatric evaluation, diagnosis, and ongoing therapeutic management services. The Psychiatrist shall render all professional services in compliance with the California Business and Professions Code, the American Psychiatric Association (APA) ethical guidelines, and all applicable federal and state regulations governing mental health practice in the State of California.
| Item # | Description of Psychiatrist Service | CPT Code | Qty | Unit Price (USD) | Extended Price (USD) |
|---|---|---|---|---|---|
| 001 | Initial Comprehensive Psychiatric Evaluation & Diagnostic Assessment (90-minute session) | 90791 | 12 | $485.00 | $5,820.00 |
| 002 | Follow-up Psychiatric Consultation & Treatment Plan Review (45-minute session) | 90792 | 36 | $320.00 | $11,520.00 |
| 003 | Psychiatric Medication Management & Prescription Renewal (30-minute session) | 99213 | 24 | $210.00 | $5,040.00 |
| 004 | Psychiatric Consultation for Referring Physicians (per consultation) | 90837 | 8 | $375.00 | $3,000.00 |
| 005 | Emergency Psychiatric Crisis Intervention (on-call, per occurrence) | 90791 | 4 | $650.00 | $2,600.00 |
| 006 | Psychiatric Progress Notes & Clinical Documentation (per patient per month) | N/A | 48 | $45.00 | $2,160.00 |
| 007 | Psychiatric Second-Opinion Review of Existing Treatment Plans | 90792 | 6 | $410.00 | $2,460.00 |
| SUBTOTAL | $32,600.00 | ||||
| Applicable Sales & Service Tax (8.75% — Los Angeles County, CA) | $2,852.50 | ||||
| TOTAL AMOUNT DUE (USD) | $35,452.50 | ||||
All services described in this Purchase Order shall be performed by the designated Psychiatrist at the practice location situated at 4730 Sunset Boulevard, Suite 310, Los Angeles, California 90027, United States, or at such other facility within the greater Los Angeles metropolitan area as mutually agreed upon in writing by both parties. The Psychiatrist shall maintain a valid California medical license, active DEA registration for controlled substance prescribing, and malpractice insurance coverage of no less than $2,000,000 per occurrence throughout the duration of this Purchase Order. Telepsychiatry sessions, where applicable, shall be conducted in compliance with the California Telehealth Practice Act and HIPAA privacy regulations.
- Acceptance: This Purchase Order shall become a binding agreement upon written acceptance by the Psychiatrist. The Psychiatrist must sign and return a copy of this document within five (5) business days of receipt.
- Payment Schedule: Invoices shall be submitted monthly. Payment is due within thirty (30) days of invoice date via ACH transfer to the account designated by the Psychiatrist. Late payments shall accrue interest at 1.5% per month.
- Cancellation & Rescheduling: The Buyer may cancel individual sessions with at least 24 hours' written notice. Cancellations made within 24 hours of the scheduled appointment shall be billed at 50% of the session fee.
- Confidentiality & HIPAA: The Psychiatrist shall maintain strict confidentiality of all patient records in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA). A Business Associate Agreement (BAA) is attached as Exhibit A.
- Compliance: The Psychiatrist warrants that all services rendered in United States Los Angeles shall comply with the California Medical Board regulations, the APA Code of Ethics, and all applicable federal and state laws governing psychiatric practice.
- Termination: Either party may terminate this Purchase Order with thirty (30) days' written notice. Upon termination, the Buyer shall pay for all services rendered up to the effective date of termination.
- Governing Law: This Purchase Order shall be governed by and construed in accordance with the laws of the State of California, United States. Any disputes shall be resolved through binding arbitration in Los Angeles County, California.
- Insurance: The Psychiatrist shall maintain professional liability (malpractice) insurance with a minimum coverage of $2,000,000 per occurrence and $5,000,000 aggregate, naming Westside Behavioral Health Group, LLC as an additional insured.
- Force Majeure: Neither party shall be liable for failure to perform obligations due to events beyond reasonable control, including but not limited to natural disasters, pandemics, or government-mandated closures affecting the Los Angeles, United States region.
By signing below, both parties acknowledge and agree to all terms, conditions, and service specifications outlined in this Purchase Order for Psychiatrist services in United States Los Angeles.
For the Buyer:
Westside Behavioral Health Group, LLC
Director of Procurement
Date: ______________________
For the Psychiatrist / Service Provider:
Dr. Jonathan R. Whitfield, M.D., F.A.P.A.
Board-Certified Psychiatrist
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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