Purchase Order Psychiatrist in United States New York City –Free Word Template Download with AI
Buyer (Purchasing Entity)
Manhattan Community Health Alliance
245 West 55th Street, Suite 1200
New York, NY 10019
United States New York City
Tel: (212) 555-0147
Email: [email protected]
Tax ID: 13-4829175
Provider (Psychiatrist)
Dr. Eleanor M. Vasquez, M.D., F.A.P.A.
Board-Certified Psychiatrist
88 Park Avenue South, Floor 14
New York, NY 10016
United States New York City
Tel: (212) 555-0392
Email: [email protected]
NY State License: PSY-2019-44871
Payment Terms
Net 30 days from invoice date
Payment Method: ACH Bank Transfer
Bank: First Republic Bank, NYC Branch
Routing: 021000021
Account: ****-6721
Delivery / Service Location
On-site at Buyer's facility
245 West 55th Street, New York, NY 10019
United States New York City
Service Window: Mon–Fri, 8:00 AM – 5:00 PM EST
| Item # | Description of Psychiatrist Service | Qty | Unit | Unit Price (USD) | Extended Price (USD) |
|---|---|---|---|---|---|
| 001 | Individual psychiatric evaluation and diagnostic consultation (per session, 60 minutes) | 120 | Session | $275.00 | $33,000.00 |
| 002 | Group psychiatric therapy facilitation (per session, 90 minutes, up to 12 participants) | 48 | Session | $450.00 | $21,600.00 |
| 003 | Psychiatric medication management and follow-up review (per session, 30 minutes) | 200 | Session | $150.00 | $30,000.00 |
| 004 | Crisis psychiatric intervention and emergency consultation (per occurrence) | 15 | Occurrence | $500.00 | $7,500.00 |
| 005 | Psychiatric case review, chart documentation, and progress reporting (monthly retainer) | 3 | Month | $2,200.00 | $6,600.00 |
| 006 | Staff training and psychiatric wellness workshop for facility personnel (per event, 3 hours) | 2 | Event | $1,800.00 | $3,600.00 |
| Subtotal | $102,300.00 | ||||
| NYC Sales & Service Tax (8.875%) | $9,079.13 | ||||
| TOTAL PURCHASE ORDER AMOUNT | $111,379.13 | ||||
Terms and Conditions
- This Purchase Order constitutes a binding agreement between Manhattan Community Health Alliance (hereinafter "Buyer") and Dr. Eleanor M. Vasquez, M.D. (hereinafter "Psychiatrist Provider") for the provision of psychiatric professional services within the jurisdiction of United States New York City.
- The Psychiatrist Provider shall maintain all required licensure, board certification, and malpractice insurance (minimum $5,000,000 per occurrence) throughout the duration of this Purchase Order. Proof of licensure under New York State Education Law, Article 139, shall be provided prior to the commencement of services.
- All psychiatric services rendered under this Purchase Order shall comply with the Health Insurance Portability and Accountability Act (HIPAA), the New York State Mental Hygiene Law, and all applicable regulations enforced by the New York City Department of Health and Mental Hygiene.
- The Psychiatrist Provider agrees to maintain strict patient confidentiality in accordance with 42 U.S.C. § 298 and New York State Public Health Law Article 28. No patient records, clinical notes, or diagnostic information shall be disclosed to any third party without written patient consent, except as mandated by law.
- Services shall be performed at the Buyer's designated facility located in United States New York City, or at such other location within New York City as mutually agreed upon in writing. The Psychiatrist Provider shall adhere to the service schedule outlined in this Purchase Order and provide a minimum of 48 hours' written notice for any schedule modifications.
- Payment shall be processed within thirty (30) calendar days of receipt of a valid invoice referencing this Purchase Order number (NYC-PSY-2025-04871). Late payments shall accrue interest at a rate of 1.5% per month as permitted under New York State General Obligations Law § 5-531.
- The Buyer reserves the right to audit service delivery records, session logs, and billing documentation related to this Purchase Order upon fourteen (14) days' written notice. The Psychiatrist Provider shall retain all clinical records for a minimum of seven (7) years in compliance with New York State record-retention requirements.
- This Purchase Order may be terminated by either party with thirty (30) days' written notice. In the event of termination, the Buyer shall compensate the Psychiatrist Provider for all services rendered up to the effective date of termination.
- Any disputes arising from this Purchase Order shall be resolved through mediation in the borough of Manhattan, United States New York City, in accordance with the rules of the American Arbitration Association. The governing law for this Purchase Order shall be the laws of the State of New York.
- The Psychiatrist Provider shall not subcontract or delegate any portion of the psychiatric services specified in this Purchase Order without prior written approval from the Buyer's Director of Clinical Operations.
Authorized by (Buyer):
Jonathan R. Whitfield, M.B.A.Director of Procurement & Vendor Management
Manhattan Community Health Alliance
Date: _______________
Accepted by (Psychiatrist Provider):
Dr. Eleanor M. Vasquez, M.D., F.A.P.A.Board-Certified Psychiatrist
Vasquez Psychiatric Services, LLC
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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