I, the undersigned, grant Annelene Naidoo permission to treat myself or legal guard in her capacity as a clinical psychologist. I hereby give permission to the therapist to interview, assess and treat me according to the guidelines and terms mentioned below
I, the undersigned, understand and acknowledge the following.
All information will be treated as confidential. There are times where a legal or ethical obligation rests on the therapist to disclose information. It is required by law to report to the appropriate authorities any suspected, past or present, child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to self or others is present, the therapist will break the confidentiality of communications. This includes receiving a court order for disclosure.
With consent, relevant information may be discussed with the referring psychiatrist or other mental health professionals registered with the Health Professions Council or South African Social Work Council.
I understand that Annelene Naidoo’s consulting fees are in accordance with the Board of Healthcare Funders of South Africa. I accept that sessions are charged at medical aid rates and are subject to annual increase.
Consultation fees are payable at the end of each session via cash or EFT, unless alternative arrangements have been agreed on. This includes any and all legal costs resulting from legal action/ debt collection for overdue accounts.
Interest accrues at 1.5% on late or overdue payments.
Sessions will be ended immediately and billed for in full, should there be the presence of intoxication or influence of substances.
Appointments need to be cancelled with 24 hours notice to avoid being billed in full. The same applies to missed appointments. This fee will be waived if a doctor’s note is produced. Appointments scheduled for a Monday, need to be cancelled by the preceding Saturday.
Should two (2) consecutive appointments be missed, the standing appointment will be cancelled going forward and will need to be rebooked.
Rescheduled appointments are subject to availability and are scheduled for the following day. Alternatively, this will be considered a cancelled/missed appointment and billed accordingly.
Patients are responsible for submitting receipts/statements for reimbursement. This practice is not responsible for failure of reimbursement from your medical aid scheme.
Psychotherapy/ assessments are purely for diagnostic and treatment purposes, and may not be used for forensic purposes.
I, the undersigned, accept full responsibility for my account and to settle any outstanding payments. Moreover, I accept full responsibility to ensure that I have received the necessary invoices for sessions that I have attended.
If my invoices are paid at private rates, I understand that it is my responsibility to make payment on the date of the therapy session. Annelene Naidoo will make available credit and debit card facilities to make this payment process possible.
The banking details are as follows:
Bank : First National Bank
Account : Annelene Naidoo
Branch Name : Northgate
Branch Code : 256755
Type of Account : Current/Cheque Account
Account Number : 62362716270
Reference : <Your Full Name>
If my invoices are being submitted to medical aid, I understand that it is my responsibility to liaise with my medical aid regarding payments due and keeping up-to-date with my available funds.
I understand that Annelene Naidoo may suspend therapy until all outstanding accounts are settled in full.
I understand that if an appointment is not cancelled within 24 hour advance notice, I will be billed in full for the sesson. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Annelene Naidoo serve as a courtesy and have no bearing on the confirmation of an appointment.
I acknowledge that phone calls and emails that are longer than 10 minutes will be charged for.
Any sessions/consultations with third parties will be charged to the undersigned, even if at the request of Annelene Naidoo. With regard to minors, feedback sessions to parents are charged in full.
I understand that that the email address and mobile number provided by me below will be used for all correspondence related to my appointments and invoices. Should I not receive the related invoice within 5 working days after a session (those that are attended or missed), I will be responsible for ensuring that I follow-up and ensure that I do have a copy of the related invoice.
I understand that this practice makes use of smeMetrics billing software and that my invoices, statements etc will be generated using this software.
I, the undersigned, accept that any late-coming will shorten the length of my session and I will be charged in full. Sessions cannot run overtime if the client is late.
Note that the information below with a ‘*’ is mandatory. If you don’t have this information, you can enter a ‘-‘. However, if the information is missing or inaccurate, it will result in a delay of the appointment scheduling, billing process and/ or medical aid follow-up process.
PROCESSING OF PERSONAL INFORMATION (POPI)
Appointments are recorded using your initials and/or first name on a password-protected electronic or hardcover diary. I need to collect and process the above and any other relevant personal information about you, including but not limited to session records/notes and communications/correspondence, that is required to provide psychotherapy services, as per HPCSA regulations and the Protection of Personal Information Act No. 4 of 2013 (POPIA).
This information will only be used for the purposes for which it was collected (providing psychotherapeutic services); the provision of such services may not be possible should you not provide this information or fail to inform me of changes or updates.
Your information will be securely stored in physical and/or electronic forms and I will review security safegurads on an ongoing basis to ensure that your information is kept safe and confidential. I may disclose your information to service providers who are involved in or enable the delivery of services to you, such as medical schemes or other health care professionals, where this is in service of your treatment and where such third parties comply with the privacy requirements as regulated by POPIA.
This may include processing and sharing information for the purpose of collecting unpaid debts. The above mentioned third parties include email and text message service providers (e.g., Gmail and webmail) and cloud storage providers (i.e., Dropbox, Google Drive and/or One Drive) who may be located outside of South Africa.
Relevant password protections will be in place to secure your information stored on these virtual platforms and I will take all reasonable steps to ensure that the privacy protections that such third parties have in place comply with the conditions of POPIA. Where specific requests are received to disclose information contained in your records (e.g., medical aid audits), a separate consent to disclosure form detailing the particulars of this request will be provided to you.
You have the right to request that I update, correct, or delete your personal information using the relevant forms as set out in POPIA (Form 1 and Form 2). These can be requested directly from me. As per the Protection of Access to Information Act (PAIA) and the processes outlined in the PAIA manual for this practice, you have the right to request a copy of the personal information that I hold about you, the copying and provision of which may be subject to payment of a legally allowable fee. The PAIA manual and Form C for requesting information can be found on the practice website or requested directly from me.
The responsibility for compliance with POPIA and PAIA lies with the registered Information Officer for this practice, Annelene Naidoo