Purchase Order Speech Therapist in United States Chicago –Free Word Template Download with AI
Lakeshore Pediatric & Developmental Health Center, Inc.
2145 N. Lake Shore Drive, Suite 480, United States Chicago, IL 60614
Phone: (312) 555-0198 | Fax: (312) 555-0199 | Email: [email protected]
Purchase Order Details
| Purchase Order No.: | PO-2025-CHIC-04872 |
| Date of Issue: | June 12, 2025 |
| Required By: | July 1, 2025 |
| Valid Until: | August 31, 2025 |
| Currency: | USD (United States Dollar) |
Vendor / Service Provider
| Name: | Dr. Margaret E. Sullivan, CCC-SLP |
| Title: | Licensed Speech Therapist |
| Practice: | Sullivan Speech & Language Therapy, LLC |
| Address: | 872 W. Madison Street, United States Chicago, IL 60607 |
| License No.: | IL-SLP-2019-44871 |
| NPI: | 1497583261 |
Bill To / Service Location
Lakeshore Pediatric & Developmental Health Center, Inc.
2145 N. Lake Shore Drive, Suite 480
United States Chicago, IL 60614
Attn: Director of Clinical Services, Mr. David R. Thompson
Line Items – Speech Therapist Services
| Item # | Description of Speech Therapist Service | Qty | Unit | Unit Price | Total |
|---|---|---|---|---|---|
| 1 | Individual Speech Therapist evaluation and diagnostic assessment for pediatric patients (ages 2–17) at the United States Chicago clinic facility. Includes articulation, language comprehension, and pragmatic language screening. | 40 | Sessions | $185.00 | $7,400.00 |
| 2 | Ongoing Speech Therapist intervention sessions (45 minutes each) for children diagnosed with speech sound disorders, language delays, or stuttering. Delivered in-person at the United States Chicago office. | 160 | Sessions | $145.00 | $23,200.00 |
| 3 | Group Speech Therapist therapy sessions (up to 4 children per group) focusing on social communication and pragmatic language skills. Conducted in the United States Chicago group therapy room. | 32 | Sessions | $220.00 | $7,040.00 |
| 4 | Written progress reports and parent/caregiver consultation sessions provided by the Speech Therapist. Includes quarterly outcome summaries and individualized home-program recommendations for families in the United States Chicago metropolitan area. | 12 | Reports | $95.00 | $1,140.00 |
| 5 | Specialized Speech Therapist training and in-service workshop for clinic staff (up to 15 participants) on evidence-based intervention strategies for childhood apraxia of speech. Held at the United States Chicago training facility. | 1 | Workshop | $1,850.00 | $1,850.00 |
| SUBTOTAL: | $40,630.00 | ||||
| Applicable Illinois State Sales Tax (6.25%): | $2,539.38 | ||||
| PURCHASE ORDER TOTAL: | $43,169.38 | ||||
Terms and Conditions
- This Purchase Order constitutes a binding agreement between Lakeshore Pediatric & Developmental Health Center, Inc. (hereinafter "Buyer") and Sullivan Speech & Language Therapy, LLC, represented by the licensed Speech Therapist Dr. Margaret E. Sullivan (hereinafter "Vendor"), for the provision of speech-language pathology services in United States Chicago.
- All Speech Therapist services shall be performed in compliance with the Illinois Department of Financial and Professional Regulation (IDFPR) licensing requirements and the American Speech-Language-Hearing Association (ASHA) Code of Ethics. The Speech Therapist must maintain active licensure in the State of Illinois throughout the duration of this Purchase Order.
- Payment terms: Net 30 days from the date of invoice receipt. Invoices must reference this Purchase Order number (PO-2025-CHIC-04872) and shall be submitted to the accounts payable department at the United States Chicago office. Late payments shall accrue interest at 1.5% per month.
- The Vendor (Speech Therapist) shall provide a minimum of 48 hours' written notice for any cancellation or rescheduling of sessions. Cancellations by the Buyer within 24 hours of a scheduled session will be billed at 50% of the session fee.
- All patient records, evaluation data, and progress documentation generated by the Speech Therapist shall remain the property of the Buyer and must be stored in accordance with HIPAA regulations and Illinois medical records retention laws. Upon termination of this Purchase Order, all records must be transferred to the Buyer within 14 business days.
- The Speech Therapist shall carry professional liability insurance with a minimum coverage of $1,000,000 per occurrence and $3,000,000 aggregate. A certificate of insurance naming the Buyer as an additional insured must be provided prior to the commencement of services in United States Chicago.
- This Purchase Order is valid for a period of twelve (12) months from the date of issue, unless terminated earlier by either party with thirty (30) days' written notice. The Buyer reserves the right to modify the scope of Speech Therapist services by issuing a written amendment to this Purchase Order.
- Any disputes arising under this Purchase Order shall be resolved through mediation in Cook County, United States Chicago, before proceeding to binding arbitration under the rules of the American Arbitration Association.
- This Purchase Order is governed by the laws of the State of Illinois. The venue for any legal proceedings shall be the Circuit Court of Cook County, United States Chicago.
Authorization and Acceptance
|
Authorized by (Buyer): David R. Thompson, Director of Clinical Services Date: ____________________ |
Accepted by (Vendor / Speech Therapist): Dr. Margaret E. Sullivan, CCC-SLP Date: ____________________ |
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