Quotation Estimate Psychiatrist in Chile Santiago –Free Word Template Download with AI
Professional Psychiatrist Services — Santiago, Chile
Ref: QE-PSY-2025-04871 | Date of Issue: 15 June 2025 | Valid Until: 15 July 2025
This Quotation Estimate is issued by Centro de Salud Mental Metropolitano SpA to provide a detailed, transparent, and itemized financial projection for the professional services of a licensed Psychiatrist to be rendered in Santiago, Chile. The purpose of this document is to inform the client of the estimated costs, scope of psychiatric care, session frequency, and all associated fees before any formal engagement or treatment plan is initiated. This Quotation Estimate does not constitute a binding contract until both parties sign and return the acceptance section at the end of this document.
The Psychiatrist services outlined in this Quotation Estimate encompass a comprehensive mental health evaluation and ongoing therapeutic care program. All services will be delivered by a board-certified Psychiatrist registered with the Colegio de Psiquiatras de Chile and holding a valid license from the Superintendencia de Salud de Chile. The Psychiatrist will conduct initial diagnostic assessments, formulate a personalized treatment plan, administer pharmacological interventions where clinically indicated, and provide follow-up consultations throughout the agreed treatment period in Santiago, Chile.
| # | Service Description | Quantity | Unit Price (CLP) | Subtotal (CLP) | Frequency |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Psychiatric Evaluation & Diagnostic Assessment (90 min) | 1 | $120.000 | $120.000 | One-time |
| 2 | Follow-up Psychiatrist Consultation & Treatment Plan Review (45 min) | 12 | $85.000 | $1.020.000 | Bi-weekly (3 months) |
| 3 | Psychopharmacological Prescription & Medication Adjustment Session (30 min) | 4 | $60.000 | $240.000 | Monthly |
| 4 | Psychological Testing & Neuropsychological Battery Administration | 1 | $180.000 | $180.000 | One-time |
| 5 | Emergency Psychiatrist Consultation (after-hours, Santiago metropolitan area) | 2 | $150.000 | $300.000 | As needed |
| 6 | Written Medical Report & Clinical Summary for Insurance / Employer | 1 | $45.000 | $45.000 | One-time |
| 7 | Telepsychiatry Video Consultation (for clients within Santiago, Chile) | 4 | $70.000 | $280.000 | Monthly |
| TOTAL ESTIMATED COST (CLP) | $2.185.000 | ||||
| TOTAL ESTIMATED COST (USD, approx. at 950 CLP/USD) | $2.300 | ||||
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, the Psychiatrist service fees may be adjusted to reflect current market rates in Santiago, Chile.
- Payment Schedule: The initial psychiatric evaluation fee (Item 1) is due at the time of the first appointment. Subsequent follow-up sessions (Item 2) are payable bi-weekly in advance. The full amount of this Quotation Estimate may also be settled in a single lump-sum payment with a 5% discount applied.
- Accepted Payment Methods: Bank transfer (transferencia bancaria) to the account of Centro de Salud Mental Metropolitano SpA, credit/debit card (Visa, Mastercard, American Express), or cash at the Santiago, Chile office. A formal invoice (factura) will be issued for every payment received.
- Cancellation Policy: Appointments must be cancelled at least 24 hours in advance. Cancellations made within 24 hours or no-shows will be charged at 50% of the session fee as stated in this Quotation Estimate.
- Confidentiality: All clinical information, psychiatric records, and treatment details are protected under Chilean Law No. 20.587 (Ley de Salud Mental) and the General Data Protection Law (Ley 19.628). The Psychiatrist will not disclose any patient information without written consent.
- Scope Limitation: This Quotation Estimate covers outpatient psychiatric services only. Hospitalization, inpatient psychiatric care, or surgical interventions are not included and would require a separate, updated Quotation Estimate.
- Location: All in-person Psychiatrist consultations will take place at the clinic located in Providencia, Santiago, Chile. Telepsychiatry sessions (Item 7) may be conducted from any location within the Santiago metropolitan area or via secure video link from anywhere in Chile.
- Regulatory Compliance: The Psychiatrist providing services under this Quotation Estimate is fully registered with the Superintendencia de Salud de Chile and the Colegio de Psiquiatras de Chile. The client is entitled to request the professional's registration number and license at any time.
- Dispute Resolution: Any disputes arising from this Quotation Estimate or the subsequent service agreement shall be resolved through the Tribunales de Justicia de Santiago, Chile, in accordance with Chilean civil and commercial law.
By signing below, the client acknowledges receipt of this Quotation Estimate for Psychiatrist services in Santiago, Chile, and agrees to the terms, conditions, and estimated costs outlined herein. This signature authorizes the service provider to schedule the initial psychiatric evaluation and commence the treatment plan as described.
Client SignatureName: ___________________________
RUT / ID: _______________________
Date: ___________________________ Authorized Representative
Centro de Salud Mental Metropolitano SpA
Name: Dr. Ricardo Fuentes M., Psiquiatra
RUT: 12.345.678-9
Date: ___________________________ ⬇️ Download as DOCX Edit online as DOCX
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