Client Consent Form and Contract :: Corporate Edge

I, the undersigned, grant Anca Wessels permission to treat myself or legal guard in her capacity as an occupational therapist.

Informed Consent

Informed consent is required by you for any treatment or procedure performed by the Healthcare Professional/s of this practice. The practice is obligated, by your individual rights, to discuss the clinical aspects, financial implications pertaining to your health status, the diagnostic process, as well as the different treatment options available to you. You have the right to withdraw your informed consent at any stage and refuse any advised medical care. Should your treatment include a referral to other Healthcare Professionals you are required to provide informed consent to their respective treatment and professional fee policies. You hereby provide consent for the exchange of clinical information between all relevant or referred Healthcare Professionals, medical schemes, and their administrators or appointed managed care organisations.

Billing Policy

This practice is not contracted to any medical aid. Patients will be charged private rates. The amount charged by Corporate Edge must be settled immediately. The onus is on the patient to submit their claim to their medical aid. It remains your responsibility to familiarise yourself with the benefits and terms and conditions associated with your chosen medical aid benefit option. It is important that you know your benefit status with regard to the extent of your healthcare cover. Also ensure that you familiarise yourself with referral restrictions, savings account balances, registration and pre-authorization processes, waiting periods and other requirements. The Medical Schemes Act 131 of 1998 and its regulations entitle members of a medical scheme to comprehensive information on their benefits and limitations of their plan. Ascertain the exact amounts your scheme provides for, in terms of consultations, procedures and treatments as well as what your medical aid will cover. Where a designated service provider has been appointed by your medical aid, it remains your responsibility as the patient to familiarise yourself with any medical and financial restrictions when consulting a non-designated service provider. With increasing interventions from your medical scheme, please be aware that the practice will not allow the medical scheme to violate the Healthcare Professional’s clinical independence. Where a medical aid or its advisors intervene to overrule your Healthcare Professional’s preferred diagnostic approach or treatment, your Healthcare Professional accepts no responsibility for consequent adverse outcomes. You may be requested to allocate responsibility to the medical aid and its medical advisors in the event of adverse treatment outcomes.

Settling Accounts

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.

Accounts will not be rendered for services not delivered, neither will accounts be delivered to someone who did not receive the service or someone legally entitled to such account. The practice reserves the right to claim directly from you in which case you will be provided with a detailed invoice that is payable within 30 days from date of service. You have the option to claim this back from your medical aid should you wish to do so. The practice actions all accounts subject to the National Credit Act, The Consumer Protection Act, the Medical Schemes Act and the Protection of Personal Information (POPI) Act. You (or your parent/guardian) remain liable for the account at all times, for services rendered by the practice even if you are insured by a medical aid or any other third party. This agreement does not prevent the practice from taking all reasonable and practical steps to recover any outstanding amounts from any obligated party. The practice reserves the right to charge interest on any outstanding account, in terms of section 2 of the Prescribed Rate of Interest Act. It remains your responsibility to inform and update all personal and medical aid information with the practice and to keep the practice regularly informed with regard to any changes on your contact details, benefits and list of dependants.

If my account has not been paid for a period of 30 days or more, the full payment will be processed against the authorised bank account. With all rights reserved, Anca Wessels has the option to use legal methods to secure payment; this may include a collection agency or small claims court, in which case the cost of such measures will be added to the claim. Notices of outstanding accounts will be served to your residential, postal and work addresses.

I understand that it is my responsibility to make payment on the date of the therapy session. Anca Wessels will make available credit and debit card facilities to make this payment process possible.

I understand that Anca Wessels may suspend therapy until all outstanding accounts are settled in full.

I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. The debit order authorisation, as completed before, will be used to process payment against your authorised bank account. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Nicole Strachen 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 Anca Wessels. With regard to minors, feedback sessions to parents are charged in full.

I understand that that the email address and mobile number provided 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, 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.

I hereby acknowledge that I have read and understood the above information. I have also been given the opportunity to ask questions prior to having signed this agreement and acknowledge that all information submitted by me is true and correct.

I understand that I am under continued obligation to advise the practice/practitioner of any changes that may occur after submission of this contract and acknowledge, by signing this contract, that I am legally bound by the provisions of the contract.

This contract is subject to the provisions of the National Credit Act, Protection of Personal Information (POPI) Act and the HPCSA ethical rules. I understand that this contract constitutes a part of the terms and conditions under which professional services will be rendered, in compliance with the Consumer Protection as well as the Protection of Personal Information Act.

The contract terms in terms of the debit order can be found lower on this page, for your reference.

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.

Title *

First Name *

Last Name *

ID Number *

Date of Birth *

Email *

Mobile Number *

Residential Address *

Residential Address Postal Code *

Postal Address

Postal Address Postal Code

Occupation

Work Telephone Number *

Person Responsible for Account – Full Name *

Person Responsible for Account – Email Address *

Person Responsible for Account – Mobile Number *

Person Responsible for Account – ID Number *

Person Responsible for Account – Home Address *

Person Responsible for Account – Home Postal Code *

Person Responsible for Account – Company Name *

Person Responsible for Account – Work Telephone Number *

Person Responsible for Account – Work Address *

Person Responsible for Account – Work Postal Code *

I have read, understood, and agree to the terms related to the medical aid payment via debit order if the medical aid claim is rejected *

I hereby declare that the information given in this intake form is true and correct to the best of my knowledge and belief. (copy) *

CONTRACT TERMS
The following are the terms of the debit order for your reference:
This signed Authority and Mandate refers to our contract as dated as on signature hereof (“the Agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our abovementioned account at my/our above mentioned bank (or any other bank or branch to which I/We may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 30 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.

The individual payment instructions so authorised to be issued must be issued and delivered as follows:
Daily; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;

I/We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

MANDATE
I/We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.

PRICING
As per outstanding invoices processed by Anca Wessels.

CANCELLATION
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

ASSIGNMENT
I/We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

AGREEMENT
By completing this form, you agree to the Terms of Use (available on our website), Website Privacy Policy (available on our website), and terms and conditions specified in your client intake contract with Anca Wessels.