Quotation Estimate Surgeon in United States Chicago –Free Word Template Download with AI
Lakeview Surgical Associates, LLC
1420 N. Lake Shore Drive, Suite 850
Chicago, Illinois 60610, United States
Phone: (312) 555-0147 | Email: [email protected]
| Quotation Estimate No.: | QEST-CHI-2025-04872 | Date of Issue: | June 12, 2025 |
| Valid Until: | July 12, 2025 (30 days) | Currency: | USD (United States Dollar) |
| Prepared For: | Dr. Margaret Ellison, MD, FACS — Chief of Surgery, Rush University Medical Center | Location: | Chicago, Illinois, United States |
| Prepared By: | James R. Whitfield, Practice Administrator | Reference: | Contract Renewal — FY 2025-2026 |
1. Purpose of This Quotation Estimate
This Quotation Estimate is formally issued by Lakeview Surgical Associates, LLC to provide a comprehensive, itemized financial projection for the engagement of a board-certified Surgeon to deliver specialized surgical services within the metropolitan area of United States Chicago. This document serves as a binding financial reference for the proposed surgical services contract and is intended to support budgetary planning, insurance pre-authorization, and institutional procurement processes in accordance with the regulations of the Illinois Department of Financial and Professional Regulation and the Chicago Department of Public Health.
The Surgeon services outlined herein encompass general surgical procedures, minimally invasive laparoscopic interventions, and post-operative care management. All rates presented in this Quotation Estimate reflect current market standards for surgical professionals operating in the United States Chicago healthcare market as of the second quarter of 2025.
2. Itemized Surgeon Services & Cost Breakdown
| # | Service Description | Quantity / Hours | Unit Rate (USD) | Subtotal (USD) | Notes |
|---|---|---|---|---|---|
| 1 | Primary Surgeon — General Surgical Consultation & Pre-Operative Assessment | 40 hours/month | $385.00 | $15,400.00 | Includes chart review, patient evaluation, and surgical planning in Chicago-area facilities |
| 2 | Surgeon — Operating Room Procedure (General Surgery, Level 1-2) | 12 procedures/month | $2,850.00 | $34,200.00 | Per-procedure fee; includes anesthesia coordination and intra-operative decision-making |
| 3 | Surgeon — Minimally Invasive / Laparoscopic Procedure (Level 3-4) | 6 procedures/month | $4,600.00 | $27,600.00 | Advanced laparoscopic and robotic-assisted techniques; includes equipment surcharge |
| 4 | Surgeon — Post-Operative Follow-Up & Wound Management | 60 patient visits/month | $195.00 | $11,700.00 | Includes suture removal, imaging review, and discharge coordination |
| 5 | Surgeon — Emergency / On-Call Coverage (24/7 Rotation) | 8 shifts/month | $1,200.00 | $9,600.00 | On-call availability at designated Chicago hospitals; response time under 30 minutes |
| 6 | Surgeon — Medical Director Oversight & Quality Assurance | 16 hours/month | $425.00 | $6,800.00 | Includes surgical outcome audits, peer review, and compliance reporting for United States Chicago regulatory bodies |
| 7 | Administrative & Billing Coordination (Surgeon Services) | 120 hours/month | $85.00 | $10,200.00 | Insurance coding, claims processing, and patient billing for all Surgeon services rendered |
| 8 | Continuing Medical Education & Licensure Maintenance | Annual | $3,500.00 | $3,500.00 | Illinois medical license renewal, CME credits, and malpractice insurance for the Surgeon |
| MONTHLY SUBTOTAL | $119,000.00 | ||||
| ANNUALIZED TOTAL (12 Months) | $1,428,000.00 | ||||
| Applicable Illinois Sales & Service Tax (10.25%) | $146,370.00 | Chicago municipal + Cook County + State | |||
| GRAND TOTAL (Annual, Tax-Inclusive) | $1,574,370.00 | ||||
3. Surgeon Qualifications & Credentials
The Surgeon proposed under this Quotation Estimate holds a Doctor of Medicine (MD) degree from the University of Chicago Pritzker School of Medicine, completed a five-year residency in General Surgery at Northwestern Memorial Hospital in Chicago, and maintains active board certification through the American Board of Surgery. The Surgeon holds an unrestricted Illinois medical license (License No. 241.008734) and is credentialed at all major hospital systems within the United States Chicago metropolitan area, including Rush University Medical Center, University of Chicago Medicine, and NorthShore University HealthSystem.
4. Terms & Conditions of This Quotation Estimate
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, all rates are subject to revision based on prevailing United States Chicago healthcare market conditions.
- Payment Terms: Net 30 days from the date of invoice. Late payments shall accrue interest at 1.5% per month in compliance with Illinois commercial code provisions.
- Scope of Services: All Surgeon services are to be rendered at pre-approved facilities within the City of Chicago and its immediate suburbs (Cook County, DuPage County, and Lake County, Illinois).
- Insurance & Liability: The Surgeon shall maintain a minimum of $5,000,000 in professional malpractice liability insurance per occurrence, with Lakeview Surgical Associates, LLC named as an additional insured party.
- Regulatory Compliance: All services shall comply with the Health Insurance Portability and Accountability Act (HIPAA), the Illinois Patient Privacy Act, and all applicable United States Chicago municipal health ordinances.
- Termination: Either party may terminate the engagement with sixty (60) days written notice. In the event of termination, a prorated portion of the Quotation Estimate total shall be settled within fifteen (15) business days.
- Force Majeure: Neither party shall be liable for delays or non-performance resulting from acts of God, pandemics, government-mandated closures, or other events beyond reasonable control within the United States Chicago jurisdiction.
- Governing Law: This Quotation Estimate and any resulting contract shall be governed by the laws of the State of Illinois, with exclusive jurisdiction in the Circuit Court of Cook County, Chicago, United States.
5. Acceptance & Authorization
By signing below, the recipient acknowledges receipt of this Quotation Estimate and agrees to the terms, conditions, and financial projections outlined herein for the engagement of the specified Surgeon services in United States Chicago. This document does not constitute a final contract until countersigned by both parties and executed in accordance with institutional procurement policies.
For Lakeview Surgical Associates, LLC:
James R. Whitfield, Practice AdministratorDate: ______________________
For the Receiving Institution:
Dr. Margaret Ellison, MD, FACSChief of Surgery, Rush University Medical Center
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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