Confidential Patient Information
Patient Details
First Name
Surname
Nationality
ID Number
Date of Birth
Email Address
Occupation
Employer
Home Address
Address 2
Post code
Cell Number
Work Number
Marital Status
- select -
Married
Widowed
Divorced
Single
Next of Kin - Please provide 2 contacts
1. Full Name
Cell Number
Email
Relationship to Patient
2. Full Name
Cell Number
Email
Relationship to Patient
Doctor
Referring Doctor
Contact Number
Family GP
Contact Number
Medical Aid and GAP Cover
Name of Medical Aid
Plan Type/Scheme
Membership No.
Dependent Code of Patient
Main Member Name
Main Member ID
GAP Cover (Patient is responsible for submitting GAP claim)
Yes
No
Person Responsible for Account (If different from patient)
Full Name
Cell Number
Email
Relationship to Patient
Occupation
Employer
Work Number
Home Number
Home Address
Address 2
Post code
Terms and Conditions
Acceptance
I, the undersigned, patient or guardian hereby agree that:
1. INTERPRETATION
1.1. "Practice" shall mean the medical practice of Dr R Endenburg and Dr M Mulder
1.2. "Patient" shall mean the name as appears on the patient application forms attached hereto
1.3. "Client" shall mean the person responsible for payment of the invoices and statements
1.4. "MedX" shall mean the billing and collections bureau employed by the Doctors to manage their billing and collections
1.5. "Services" shall mean visits, appointments, procedures performed and care provided by the Doctors of this practice
2. FEES:
2.1. I am aware that:
2.1.1. The fees in this practice are approximately 2,5 to 3 times the basic Medical Aid Rate
2.1.2. Medical Association of SA rates and Health Professionals Council of SA Ethical rates are 3 x the basic Medical Aid Rate
2.1.3. My Medical Aid decides independently what contribution it is prepared to make to this practice. As a result, the practice does not deal directly with any Medical Aid
2.1.4. The fees in this practice exclude the costs of the hospital, and any other specialists or therapists involved in the procedure or in the care before and after the procedure
2.2. I have been given ample opportunity to ask any questions I may I have regarding fees charged before treatment has started
3. PAYMENT
3.1. I am personally responsible for payment and not my Medical Aid
3.2. Payment is due within 14 days of the date of the invoice
3.3. As this practice is NOT contracted in to all Medical Aids, the medical scheme may pay their portion of the Doctors fees into my or the main member's bank account. This is not my money to spend and should be used to finalise the account, together with the balance owed within 7 working days
3.4. In the event of Divorce, the parent accompanying the minor and signing the patient form is responsible for settling the account
3.5. Payment for a consultation is due before leaving the rooms on the day of the visit
3.6. Should I pay by means of cheque through post, the risk of such payment falls onto me, the client
3.7. I am not entitled to withhold payment for any reason whatsoever and agree that no extension of payment of any nature shall be extended to me unless such extension is agreed in writing by the practice and signed by the duly authorised representative of the practice
4. OVERDUE ACCOUNTS
4.1. In the event of any legal demand or action, I shall be liable for a) interest, at a rate of 10% annually, compounded monthly, b) all legal costs incurred by the practice on an attorney and client scale and c) administration costs amounting to a 25% administration fee on each instalment paid
5. BREACH
5.1. If I commit a breach of any of these terms and conditions or provide false or inaccurate information, the practice can terminate services and proceed to institute proceedings in terms of this clause for overdue accounts or any amounts due to the practice
5.2. The practice shall be entitled to recover all costs incurred by it in enforcing its rights under any agreement, on an attorney and own client basis together with claims for all costs including collection commission; tracing charges and interest on outstanding debt compounded monthly as stated in clause 4 above
5.3. Once my account has been handed over for legal action, no further correspondence shall be entered between the practice and me. All correspondences shall be made with MedX
5.4. The practice shall be entitled to institute any legal proceedings against me in any Magistrate's Court having jurisdiction in respect of the client
5.5. I consent to the jurisdiction of the Cape Town Magistrates Court in respect of all matters arising from any breach of these terms and conditions or its cancellation
5.6. I choose my domicilium citandi et excutandi for all purposes as my address as stated in this "Confidential Patient Information" form. It is my duty to provide written proof of change of address within 7 days' notice; failing which the domicilium citandi et excutandi will be applicable
6. CONFIDENTIAL PATIENT INORMATION
6.1. MedX is the medical billing and collections bureau employed by Dr Endenburg and Dr Mulder to manage billing and collecting of invoices on their behalf. MedX is obliged to maintain the confidentiality of patient information. The patient consents to the disclosure of their information to MedX for the purposes of billing and collection services
6.2. The patient also agrees that his/her clinical records, X-rays and pictures may be used for research, congress presentations and journal articles. The patient's name however will not be disclosed at any time
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