Patient Terms and Conditions
Please read this agreement carefully
INFORMED CONSENT
I understand that I have the right to ask my doctor to explain and disclose medical
information to me before I agree to a medical procedure or treatment, including
the following:
• different treatment options available to me;
• common and severe side effects of specific treatment options;
• the benefits, risks, costs, and consequences associated with each option;
• details of the diagnosis and prognosis, and the likely prognosis if the condition is
left untreated;
• any uncertainties regarding the diagnosis;
• how and when my condition and any side effects will be monitored or re-
assessed;
• the name of the doctor who will have overall responsibility for the treatment;
• that I have the right to seek a second opinion at any time;
• And I confirm that this information has been provided to me.
GENERIC MEDICINE
I understand and acknowledge that my Medical Scheme may insist that I
substitute medicine that appears on my prescription with its generic equivalent. It
is within my doctor’s sole discretion and clinical judgement whether or not to allow
for the generic substitution of my medicine and no substitution may take place
where the doctor has written ‘no generic substitution’ on my prescription.
DISCLOSURE OF MEDICAL INFORMATION
I hereby authorize:
• the use and disclosure of my medical information to any relevant specialist as my
primary doctor may see fit;
• that a copy of my medical record will be kept by my doctor on file. I have been
made aware that all consultations and interaction with the doctor are subject to
electronic storage and copies will be stored in a secure server as part of practice
note-keeping for the personal use of the doctor;
• the disclosure of relevant medical information to my Medical Scheme – will
typically include diagnoses, ICD10 codes and procedural codes;
• the practice to have access to my hospital records, radiology & laboratory
results.
PRIVACY OF MEDICAL INFORMATION
I hereby authorize:
• the use and disclosure of my medical information to any relevant specialist as my
primary doctor may see fit;
• that a copy of my medical record will be kept by my doctor on file. I have been
made aware that all consultations and interaction with the doctor are subject to
electronic storage and copies will be stored in a secure server as part of practice
note-keeping for the personal use of the doctor;
• the disclosure of relevant medical information to my Medical Scheme – will
typically include diagnoses, ICD10 codes and procedural codes;
• the practice to have access to my hospital records, radiology & laboratory
results.
PAYMENT OF MEDICAL COSTS
I acknowledge that:
• I have been informed that this practice does not necessarily charge the rates that
my Medical Scheme may have decided upon;
• My Medical Scheme may or may not cover all the fees charged by this practice.
Should there be a shortfall, I remain personally liable for payment of that
shortfall;
• I undertake to settle all fees incurred through elective or emergency consultation,
deliveries, procedures, or care otherwise provided irrespective of my agreement
with my medical Scheme. If there is any delay or dispute (by my insurer or other)
regarding payment, I undertake to settle the account personally within 30 days of
services rendered;
• I am fully responsible for payment and should I not pay timeously, I will be liable
for debt recovery & legal costs;
• I am also aware that there will be annual increases in practice fees for all
consultations, deliveries and procedures, and that unless a formal quotation for a
specific procedure is accepted in writing by both client and provider, these cost-
increases will apply to all patients (usually effective 1 January of each year).
INTEREST ON OVERDUE ACCOUNTS
I am aware that 2% interest and administrative costs will be charged per month
(after 60 days) for all overdue accounts and that legal steps will be taken by the
practice with any additional costs incurred to be added to my account.
MEDICAL CERTIFICATES ('SICK NOTES')
I hereby acknowledge that I understand that although I am entitled to ask for a
medical certificate from my doctor, he/she is under no obligation to issue such a
certificate. My diagnosis will only be disclosed on the certificate provided I have
given my written consent, and the decision who I want to show the certificate to is
at my sole decision.
PRE-AUTHORISATION
I am fully aware that if a treatment requires hospitalization, I am personally
responsible for ensuring that pre-authorization is obtained from my medical
scheme BEFORE I undergo the procedure. If my medical scheme declines
payment for any reason whatsoever, I remain responsible for making full
payment for the services rendered to me.
My Medical Scheme may request information or formal motivation from my doctor
before authorising the procedure. I acknowledge that I am responsible to pay for
the costs of such motivation or information supplied to my medical scheme.
ICD-10 DIAGNOSTIC CODING
Regulation 5(f) of the Medical Schemes Act (published in the Government
Gazette NO 20566 on October 20th,1999) states that an account to the
Medical Scheme must contain the relevant diagnosis. This must be
submitted as an ICD-10 diagnostic code (number allocated to your diagnosis
by the international classification of diseases) and may be used in referral
letters, requests for special investigations and prescriptions. Failure to submit
the correct codes might lead to a claim incorrectly paid or not paid at all.
MEDICAL RESEARCH
I understand that diagnostic and procedural information (as well as any
related photographs) related to my treatment may be utilized for practice
statistical, research and / or teaching purposes. All such information will be
dissociated from patient information and informed consent will be obtained by
the practice if any of my information is required for clinical trials or research. I
have the right to decline the taking of photography or the use of any images
by the practice.
CONSENT TO PROCESS PERSONAL INFORMATION
I acknowledge that my personal information needs to be processed by the
practice and therefore grant the following consent:
I acknowledge and accept that the medical practice will during the course of
rendering services to me, collect and have access to my personal
information, including information relating to my race, gender, sex,
pregnancy, marital status, national, ethnic, or social origin, colour, sexual
orientation, age, physical or mental health, well-being, disability, religion,
conscience, belief, culture, language, identifying number, symbol, e-mail
address, physical address, telephone number, location information, online
identifier and my biometric information.
I grant my express consent for the practice to collect and process this
information for the purpose of rendering services to me as well as
processing claims with medical schemes or insurance funders.
Administrative staff employed in the practice may be granted access to my
personal information contained in my health record, including any clinical
notes, in order to process claims to medical schemes, issuing of
documentation or any other administrative function required by the practice.
The practice makes use of a medical billing service company, namely
Xpedient Medical (Pty) Ltd and I grant my consent to the processing of my
medical information by Xpedient Medical as is required to process claims
with medical schemes.
I accept that my personal information will be accessed and processed by my
Medical Scheme and/or health insurer and grant the practice and Xpedient
Medical consent to transmit that information as required to process any
claims.
I accept that my personal information will only be utilized for the purpose it
was collected for and that the information will only be retained for as long as
is necessary and required by law, and that I have the right to view such
information at any time.
GENERAL
I hereby confirm that:
• I have freely chosen this practice to consult with and render service to me;
• I am aware that my doctor’s availability is limited to office hours and
consulting times.
• I am under the obligation to inform the practice of changes to my personal,
medical and/or financial information;
• I hereby understand that my doctor has the right to change his/her mind
about a medical decision at any time;
• I have had an opportunity to review these terms and conditions and that
this form accurately reflects my wishes;
• I have read and understood each of the terms and conditions contained in
this agreement;
• I have a right to inspect and/or copy these terms and conditions;
• I am signing these terms and conditions voluntarily;
• I have been informed that should my medical scheme not settle the
account of the practice in full, I hereby consent to authorise the practice to
challenge my medical scheme at the Council for Medical Schemes on my
behalf.
I agree that all the information that I have supplied is true and correct to the
best of my knowledge. I have read, understand, and accept the content of
these terms and conditions. And acknowledge and accept that they are
legally binding upon me.