Healthcare Work Order Quote

HEALTHCARE WORK ORDER QUOTE

Quote Number:    Date Issued:

Client / Patient Information

Date of Birth:    Gender: Female Male Other

Service Provider Information

License / Certification ID:    Insurance Carrier:    Policy No.:

Scope of Work

Itemized Estimate

Description          Quantity        Unit Price        Line Total

Subtotal:    Taxes / Fees:    Total Estimated Cost:

Schedule & Access

Estimated Start Date:    Estimated Completion Date:

Materials & Equipment

Vendor Provides Materials:    Client Provides Materials:

Compliance, Safety & Privacy

By checking the following boxes, the signer certifies the statements are true and may be relied upon by the Provider in planning and performing the work.

Vendor will comply with facility infection control and safety protocols:

Vendor may need access to patient areas and may be exposed to Protected Health Information (PHI). Client acknowledges vendor and its personnel will adhere to applicable privacy rules and facility policies while performing work:

Terms, Warranty & Liability

Payment Terms: Unless otherwise agreed in writing, payment is due within 30 days of invoice. Client agrees to pay all undisputed amounts. Late payments shall accrue interest at the lesser of 1.5% per month or the maximum permitted by law.

Change Orders: Any change in scope, schedule, materials, or access that affects cost or schedule shall be documented in a written change order signed by both parties prior to implementing the change. Provider is not responsible for delays or additional costs resulting from out-of-scope work performed without a signed change order.

Warranty: Provider warrants labor and materials supplied by Provider for a period of 90 days from completion unless a different warranty period is stated in writing. This warranty does not apply to wear and tear, misuse, or failure caused by client-supplied materials or alterations by others.

Insurance and Indemnity: Provider represents that it maintains commercial general liability and, where applicable, professional liability insurance. Provider and Client shall each indemnify and hold the other harmless from claims arising from their respective negligence or willful misconduct, subject to applicable law.

Limitation of Liability: Except for willful misconduct or gross negligence, neither party shall be liable to the other for incidental, consequential, or punitive damages. Provider's aggregate liability for any claim arising from this quote or the work shall not exceed the total amount paid to Provider under this quote.

Quote Validity: This quote is valid for days from the Date Issued shown above unless extended in writing by Provider.

Acceptance

By signing below, Client accepts this Healthcare Work Order Quote, authorizes Provider to proceed with the described work in accordance with these terms and any executed change orders, and certifies that the signer is authorized to bind the Client named herein.

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