Purchase Order Surgeon in United States Chicago –Free Word Template Download with AI
Medical Professional Services Procurement Document
PO No. US-CHI-2025-04872
Date of Issue: June 15, 2025
Valid Until: September 15, 2025
Buyer / Requiring Department
Lakeview Medical Center
2145 N. Lake Shore Drive
Chicago, Illinois 60614
United States
Attn: Dr. Margaret Ellison, Chief of Surgery
Phone: (312) 555-0198
Email: [email protected]
Tax ID: 36-4829105
Supplier / Service Provider
Dr. James R. Whitfield, M.D., F.A.C.S.
Board-Certified General & Vascular Surgeon
Whitfield Surgical Associates, LLC
875 W. Madison Street, Suite 420
Chicago, Illinois 60607
United States
Phone: (312) 555-0342
Email: [email protected]
NPI: 1497823651
IL Medical License: 231.004872
Payment Terms
Net 30 days from date of invoice
Payment Method: Electronic Funds Transfer (EFT)
Bank: First Midwest Bank, Chicago Branch
Routing No.: 071000013
Account No.: ****-****-4821
Delivery / Service Location
Lakeview Medical Center – Operating Theatres 1 through 6
Chicago, Illinois 60614, United States
Service Period: July 1, 2025 – December 31, 2025
On-call availability: 24/7 as required
| Item # | Description of Surgeon Services | Quantity | Unit | Unit Rate (USD) | Extended Amount (USD) |
|---|---|---|---|---|---|
| 1 | General Surgical Procedures – Elective (Laparoscopic Cholecystectomy, Hernia Repair, Appendectomy) performed by the Surgeon at Lakeview Medical Center, Chicago | 45 | Procedures | $4,200.00 | $189,000.00 |
| 2 | Vascular Surgery – Elective (Peripheral Artery Bypass, Varicose Vein Stripping) performed by the Surgeon in the United States Chicago facility | 20 | Procedures | $6,800.00 | $136,000.00 |
| 3 | Emergency Surgical Consultation and Intervention – On-call Surgeon availability for trauma and acute abdominal cases at the Chicago hospital | 12 | Months | $8,500.00 | $102,000.00 |
| 4 | Post-Operative Patient Follow-Up and Wound Management by the Surgeon – Scheduled clinic visits in Chicago, Illinois | 180 | Visits | $250.00 | $45,000.00 |
| 5 | Surgical Case Review, Peer Consultation, and Quality Assurance Participation by the Surgeon for the United States Chicago surgical department | 12 | Sessions | $1,200.00 | $14,400.00 |
| 6 | Resident and Fellow Surgical Training Supervision by the Surgeon – Mentorship program at Lakeview Medical Center, Chicago | 12 | Months | $3,000.00 | $36,000.00 |
| TOTAL PURCHASE ORDER AMOUNT | $522,400.00 | ||||
Terms and Conditions
- This Purchase Order constitutes a binding agreement between Lakeview Medical Center (hereinafter "the Buyer") and Dr. James R. Whitfield, M.D. (hereinafter "the Surgeon") for the provision of surgical and related medical professional services within the United States Chicago metropolitan area.
- The Surgeon shall perform all surgical procedures in strict compliance with the standards established by the American College of Surgeons (ACS), the Illinois Department of Public Health, and all applicable federal and state regulations governing surgical practice in the United States.
- The Surgeon warrants that all services rendered under this Purchase Order shall be performed with the degree of skill, care, and diligence expected of a board-certified surgeon practicing in Chicago, Illinois, and shall maintain current malpractice insurance coverage of no less than $5,000,000 per occurrence.
- Payment for services rendered under this Purchase Order shall be due within thirty (30) calendar days of receipt of a valid invoice. Late payments shall accrue interest at a rate of 1.5% per month as permitted under Illinois commercial law.
- The Surgeon shall maintain a minimum on-call availability of 48 hours per week at the Lakeview Medical Center facility in Chicago. Failure to meet on-call obligations without prior written notice to the Buyer shall result in a service credit of $500 per missed shift.
- All patient records, surgical reports, and clinical documentation generated by the Surgeon in connection with this Purchase Order shall be maintained in the electronic health record system of Lakeview Medical Center and shall comply with HIPAA (Health Insurance Portability and Accountability Act) regulations as enforced in the United States.
- This Purchase Order may be terminated by either party with sixty (60) days written notice. In the event of termination, the Buyer shall compensate the Surgeon for all services rendered through the effective date of termination.
- Any disputes arising from this Purchase Order shall be resolved through binding arbitration in Cook County, Chicago, Illinois, in accordance with the rules of the American Arbitration Association.
- The Surgeon shall not subcontract or delegate any surgical procedures to another physician without the prior written consent of the Buyer's Chief of Surgery.
- This Purchase Order is governed by the laws of the State of Illinois and the federal laws of the United States of America. The venue for any legal proceedings shall be the Circuit Court of Cook County, Chicago, Illinois.
Authorized by (Buyer):
Dr. Margaret Ellison, M.D.Chief of Surgery, Lakeview Medical Center
Date: _______________
Accepted by (Surgeon / Supplier):
Dr. James R. Whitfield, M.D., F.A.C.S.Whitfield Surgical Associates, LLC
Date: _______________
Approved by (Finance):
Robert T. Callahan, CPADirector of Procurement & Finance
Lakeview Medical Center, Chicago
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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