Main Member Information: ID Number Title Full name(s) (required) Initials (required) Surname (required) Gender (required) —Please choose an option—MaleFemale Home language Date of Birth Cell Number Home Number Work Number Employer: Your Email (required) Email statements? YesNo Postal address: Physical address: Main member accepts this address as their domicilium citandi et executandi address Medical scheme: *Plan option: Membership No: Gap cover: YesNo M/M Dep code: Spouse Information: Spouse's Full name(s): Spouse's Surname: Spouse's email: ID number: Spouse Cell: Spouse Work: Patient / Child's Information: Date of Birth: Full Name(s): Surname: Initials: Nickname: Home Language: Title: Date of birth: Gender: —Please choose an option—MaleFemale Relationship to Main member: * Patient Dep code: Age (years): Referring Doctor (if applicable): Next of Kin (Not from the same physical address): Full Name(s): Surname: Cell Number: Initials: Title: Relationship to patient: I, the undersigned, hereby Acknowledge that I have been informed that this practice may not charge the rates that my Medical Aid has decided upon. Confirm that I have been informed that this practice charges the premier rates as per the market leader (for more information on the rates we charge for specific services please contact our rooms). Confirm that I am aware that the values for services are available from my Medical Aid according to the option I have chosen. Understand that my Medical Aid and plan of choice may or may not cover all the fees charged by this practice (for more information regarding which benefits your chosen medical aid plan includes and/or excludes please contact your medical aid scheme). Accept that I am fully responsible for payment for services rendered and should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale. Understand that this practice takes the privacy of its patient very seriously and has implemented reasonable security measures to guard against the unauthorised disclosure of my patient information. Acknowledge that my patient information may be disclosed by this practice in response to a specific request by a law enforcement agency, subpoena, court order, or as required by law. Confirm that I have read and understand each of the terms and conditions contained in this agreement. Acknowledge that I am signing these terms and conditions voluntarily without being forced, influenced, pressured or harassed to do so. Understand the implication and agree to the doctor and or/practice disclosing my ICD-10 diagnosis code(s), where appropriate. Hereby I confirm that the information I supplied is true and I am responsible for any false information provided. Name in print: Date of signature: Allow mass communication or notices from practice: —Please choose an option—YesNo All fields marked with * are mandatory. Please note that you (or your parent/guardian) remain liable for the account for services rendered by this practice, even if you are insured by a medical aid or other third party. Please ensure that you have read and signed the attached Doctor-Patient contract below: TERMS AND CONDITIONS AGREED TO BY PARENTS AND LEGAL GUARDIANS 1. CHILDREN AND HEALTHCARE You confirm that you understand that, as a parent or legal guardian, you are legally liable to cover the cost of your child’s healthcare. This practice does not know what the specific arrangements are between unmarried-, married-, divorced-, foster or other parents or caregivers. 2. Unless a signature of the person responsible for the account, in terms of a parental agreement, is provided, the parent / guardian / caregiver who signs the practice forms and accepts these terms and conditions will be held legally liable for the cost of care provided and the account will be addressed to that person. The practice regrets that it cannot get involved in parental disputes as to the financial aspects of healthcare provided to a child or children. 3. PRICING/FEES AND PAYMENT Fees are set according to the following principles: a) This Practice bills according to a billing policy. We charge rates which we believe are commensurate with the experience of our practitioners, and which corresponds with the highly, patient-intensive, specialised and high-risk nature of the services we provide. b) The general fees the Practice charges for commonly used billing codes and estimated values for certain types of interventions (e.g. premature babies in ICU), are available on request from our staff. For healthcare that may depend on the duration and intensity of the care required, and for hospital / ICU-based case, we provide illustrative values for the practitioners’ fees. c) The terms and tariffs applicable to medical scheme patients vary from scheme to scheme, and even from option to option (plan to plan). You have to obtain those details from your scheme. If you are concerned about the amounts, you have to talk to your scheme. d) Our fees only cover visits and care provided by the doctors of this practice, whether in the rooms or in hospital. e) Our fees exclude the costs of the hospital (admission, ward, ICU, theatre and other fees), anaesthetists, pathologists (for blood tests), radiologists (for X-rays and scans) and therapists involved in your child’s care. You have to discuss their fees with them. 4. Please note that the cost of healthcare sometimes depends on how your child reacts to treatment. The law requires of us to step in to save your child’s life, or to prevent or reduce harm to your child. We will charge for the costs of this. 5. All accounts must be settled within 30 calendar days of the date on the account. 6. By choosing the Practice, you – a) Consent to us submitting the account to your medical scheme. This does not mean that the scheme has received the account or that they accept liability for the account. Please confirm that with them. b) Confirm that the person indicated on the practice form as belonging to the scheme as principal member or dependent, is indeed a member with a valid membership at the date of visiting the practice. 7. All accounts must be settled within 30 calendar days of the date on the account. You remain fully liable to settle the full account, irrespective of whether your scheme gave pre-authorisation or whether there was an assumption of payment or partial not. In some cases, medical schemes will only pay a portion of the treatment costs, and there is then still a part of the costs/fees outstanding. You are liable to pay this to us within 30 calendar days of the date appearing on the account you receive from us. 8. If your account is not paid after the 30 calendar days, we will, in terms of the National Credit Act, give notice of 20 working days that your account is in arrears. If you fail to settle the account within another 10 days, the account will be handed over for debt collection. This may result in you having a bad credit record. 9. You hereby confirm that the address provided to the Practice is the address where you agree to accept all notices and/or summons. 10. We will charge, in our sole discretion, the maximum amount of 2% interest, as allowed by the National Credit Act, per month on all outstanding accounts. You will also be responsible for all costs relating to the debt collecting, such as commissions and fees levied by the debt collector or attorney. 11. If you feel that your medical scheme should have paid in full, you can lay a complaint at the Council for Medical Schemes by fax: (012) 431 0608 or email: complaints@medicalschemes.com. Please inform the practice should you require assistance in this regard. 12. ON TIME OF PERFORMANCE OF SERVICE Although we will do our best to render the services at the time we set, neonatology and healthcare to children is uncertain by its very nature. Our doctors may have to rush off to assist a child who requires such urgent assistance, or may be with a child that requires more time. Emergencies must, by law, get preference. By agreeing to our services, you agree to this uncertainty. We will, if possible, inform you if we run late. Full Name We request 24 hours’ notice of cancellation of an appointment. Should we not be notified of your cancellation and you do not attend the appointment, you will be liable for 50% of the fees charged by the doctor for that consultation. CONFIDENTIALITY This document constitutes a contractual agreement by the practice to protect all personal information in confidence. We will use your child’s and your information only in relation to your healthcare, which means that we may also use this information when we interact with your medical scheme and the hospital. We can only release information with your written consent, even if a family member requests the information. Please provide us with that consent if you want us to be able to disclose certain information to your family. The following special cases exist where the law compels us to disclose your child’s information and by agreeing to our services, you acknowledge this legal duty that we have to disclose: a. To your medical scheme: a diagnostic code and details of the treatment and/or operation, so that the scheme can evaluate whether it falls within your benefits. b. To a referring healthcare professional and others involved in your child’s healthcare, in terms of the National Health Act: information that is necessary to protect your child’s interest. PURPOSE AND NATURE OF HEALTHCARE You confirm that you understand that in healthcare results cannot be guaranteed. Results also depend on how a child’s body reacts to treatment. You confirm that you understand that your own behaviour or that of a child may affect the outcome of the healthcare received. You agree to follow the instructions provided to you by the healthcare professionals and/or come for follow-ups, etc. If you do not do this, you undertake to not hold the Practice and its staff liable for any negative consequence. (initial) EQUIPMENT, DEVICES AND MEDICINES (“GOODS”) WE USE If we have to substitute a medicine or device with another one, we will obtain your consent for that. If you are offered a substitution at a pharmacy level, ask the pharmacist whether such substitution would be in your child’s best interest, or ask us at the practice. Remember that the law only allows for generic substitution (the same molecule) and does not permit therapeutic substitution (another molecule). In general, science behind medicines is that one should not switch from one product to another, and should take care before switching in babies and patients who are critically ill. If there is a proven quality or performance fault with the goods, we will contact the supplier, who will deal with the matter. Note that each manufacturer may have its own rules in this regard. PATIENT / CLIENT / CONSUMER DUTIES (NATIONAL HEALTH ACT, 2003) You must adhere to the rules of the Practice and any instructions given to you by staff or healthcare professionals. You have the right to ask questions and to have them answered. If you do not ask any questions, we will assume that you have understood- and agree to what is being discussed. You and/or your family or other persons that come to the Practice should not harass the healthcare professionals and staff. They must be treated with respect. If not, we are allowed by law to refuse to treat- or to continue to treat your child(ren). In such cases we will refer you to another Practice. SIGNATURE: 13. CANCELLATION FEE Signature of patient / parent / guardian confirming that s/he understood and agrees to the above terms and conditions: Relationship of signatory to child-patient(s): MotherFatherAdoptive motherAdoptive fatherLegal guardian GrandmotherGrandfatherCaregiver Other: (please complete) Please ask us if you do not understand any of the clauses above.