Purchase Order Psychiatrist in United States San Francisco –Free Word Template Download with AI
Professional Mental Health Services — Psychiatrist Consultation & Treatment Program
Issued in United States San Francisco, California
Purchase Order No.: PO-SF-2025-04872 | Date of Issue: June 12, 2025 | Status: APPROVED
Issuing Organization (Buyer)
Bay Area Wellness Collective, Inc.
1450 Market Street, Suite 2200
United States San Francisco, CA 94102
Phone: (415) 555-0187
Email: [email protected]
CA Business License: #1847293
IRS EIN: 94-2837461
Service Provider (Vendor)
Dr. Elena Vasquez, M.D., Board-Certified Psychiatrist
Golden Gate Psychiatric Associates
880 Montgomery Street, Floor 14
United States San Francisco, CA 94133
Phone: (415) 555-0342
Email: [email protected]
CA Medical License: A-118472
NPI: 1093847265
This Purchase Order authorizes the procurement of the following Psychiatrist services to be rendered in United States San Francisco by the designated provider. All services shall comply with California Board of Psychology and Medical Board regulations as well as applicable federal HIPAA standards.
| # | Service Description | Qty | Unit | Unit Price (USD) | Extended Price (USD) | Service Period |
|---|---|---|---|---|---|---|
| 1 | Initial comprehensive Psychiatrist evaluation and diagnostic assessment, including psychiatric history, mental status examination, and formulation of treatment plan | 1 | Session (90 min) | $450.00 | $450.00 | Jun 20, 2025 |
| 2 | Follow-up Psychiatrist consultation for ongoing treatment management, medication review, and therapeutic progress evaluation | 12 | Session (60 min) | $325.00 | $3,900.00 | Jun 27 – Sep 26, 2025 |
| 3 | Psychiatrist-prescribed psychopharmacological management including medication titration, side-effect monitoring, and quarterly lab work coordination | 4 | Quarterly cycle | $185.00 | $740.00 | Jun – Sep 2025 |
| 4 | Emergency Psychiatrist telehealth consultation (after-hours crisis intervention via secure video platform, available 24/7 in United States San Francisco service area) | 2 | Session (45 min) | $275.00 | $550.00 | As needed |
| 5 | Psychiatrist-authored clinical documentation, progress notes, and referral letters for multidisciplinary care coordination with primary care and behavioral health teams | 1 | Annual package | $350.00 | $350.00 | Jun 2025 – May 2026 |
| 6 | Psychiatrist-led group psychoeducation workshop (maximum 12 participants) on stress management, anxiety reduction, and medication adherence, held at the provider's United States San Francisco office | 2 | Workshop (2 hrs) | $600.00 | $1,200.00 | Jul 15 & Aug 15, 2025 |
Subtotal: $7,190.00
Applicable Sales Tax (CA 8.75% — exempt as medical service): $0.00
Administrative Processing Fee: $120.00
Total Purchase Order Amount: $7,310.00 USD
Terms, Conditions & Compliance Notes
- Scope of Services: This Purchase Order is issued specifically for Psychiatrist services to be delivered by Dr. Elena Vasquez at her licensed practice in United States San Francisco. No substitution of the designated Psychiatrist is permitted without prior written approval from the procurement officer of Bay Area Wellness Collective, Inc.
- Payment Terms: Net 30 days from the date of invoice submission. Payment shall be made via ACH transfer to the account on file. Late payments shall accrue interest at 1.5% per month as permitted under California Commercial Code Section 2210.2.
- Confidentiality & HIPAA: All patient records, clinical notes, and Psychiatrist-generated documentation are subject to the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA). The Psychiatrist and Golden Gate Psychiatric Associates shall execute a Business Associate Agreement (BAA) prior to the commencement of services.
- Licensing & Credentialing: The Psychiatrist must maintain an active California Medical Board license, DEA registration for controlled substance prescribing (if applicable), and malpractice insurance with a minimum coverage of $2,000,000 per occurrence. Proof of current licensure must be provided upon request.
- Service Location: All in-person Psychiatrist consultations, evaluations, and workshops referenced in this Purchase Order shall take place at the provider's office located at 880 Montgomery Street, United States San Francisco, CA 94133, or at an alternate location within the San Francisco Bay Area as mutually agreed in writing.
- Cancellation & Rescheduling: Appointments may be rescheduled with a minimum of 48 hours' notice. Cancellations with less than 48 hours' notice shall be billed at 50% of the session fee. This Purchase Order remains valid for a period of 90 days from the date of issue.
- Dispute Resolution: Any disputes arising from this Purchase Order shall be resolved through mediation in United States San Francisco, California, in accordance with the California Uniform Arbitration Act. The prevailing party shall be entitled to recover reasonable attorney's fees.
- Force Majeure: Neither party shall be liable for failure to perform obligations under this Purchase Order due to acts of God, natural disasters, pandemics, or governmental actions affecting the United States San Francisco metropolitan area, provided that the affected party gives prompt written notice.
- Acceptance of Services: Services shall be deemed accepted upon completion of each session or deliverable unless the buyer provides written notice of non-conformance within five (5) business days of the service date.
- Governing Law: This Purchase Order shall be governed by and construed in accordance with the laws of the State of California, with venue in the Superior Court of California, County of San Francisco.
Authorized by (Buyer):
Michael TorresDirector of Procurement
Bay Area Wellness Collective, Inc.
Date: _______________
Accepted by (Vendor / Psychiatrist):
Dr. Elena Vasquez, M.D.Board-Certified Psychiatrist
Golden Gate Psychiatric Associates
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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