I, the undersigned, grant CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route permission to treat myself or legal guard in their capacity as audiologists. I hereby give permission to the therapist/s to interview, assess and treat me according to the guidelines and terms mentioned below

I, the undersigned, understand and acknowledge the following.

I understand that payment for services rendered and or products supplied remains my responsibility and agree to pay for all services rendered. I agree that should the account be handed over for collection, I shall be liable for all legal fees, charges and expenses. I agree that the account is subject to the Prescribed Rate of Interest Act and that I remain liable for interest on account/s that have not been settled in 60 days.

I agree to a negative listing of my credit information should my account remain outstanding for more than 60 days. Should I insist that services or materials be provided by CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route, which is contrary to the advice or recommendations received, I shall not hold the practice, the audiologist, practice owner and or the employees of the business and or the franchisor liable for any consequences which may be harmful or not to my liking.

I also agree that further costs to remedy the situation will be for my own costs. Should damage occur to any appliance as a result of gross negligence on my part, I will be responsible for additional costs for corrective or replacement work.

Minor patients

I confirm that although I am not the natural parent or legal guardian, I am duly authorized by the parent/guardian to accompany the minor. The parent/guardian has further also acknowledged their liabilities relating to cost incurred by CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route.

I acknowledge that the capture , storage and use of my personal information by CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route is necessary to ensure updated contact details and a complete medical record related to my medical history in order for accurate diagnoses to be made with the appropriate treatment and/or corrective measures at any time, either by CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route or a third party which may include my medical aid and/or another practitioner. I understand that in situations where my personal information is passed on to a third party with my consent such information thereafter falls outside of the control of CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route.

Medical Aid Members

I agree and understand that this contract is entered between me / us and the practice and not the practice and the Medical Aid. This practice will claim from my Medical Aid, on my behalf, but the member of the medical aid will at all times stay responsible for ensuring all claims are submitted, received and settled by the Medical Aid.

I understand that CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route take great care in telephonically and/or electronically confirming benefits BUT benefits are not guaranteed by my Medical Aid. CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route will not be held responsible for any changes, for whatever reason, in benefits resulting in short payments, between the time of benefit confirmation and actual payment by the medical aid. In Accordance with ICD-10 legislation, CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route is obliged to disclose diagnostic codes on all medical aid claims.

I understand that appointments need to be cancelled not less than 24 (twenty four) hours in advance.
Failure to cancel an appointment within the given time frame may result in a cancellation or missed appointment fee being levied against me. Furthermore I understand that cancellation and missed appointment fees are not covered by me medical aid scheme and that I will remain responsible for the payment of these fees.

I understand 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 understand that this practice makes use of an external practice administration firm Kitrin (Pty) Ltd. Services administered by Kitrin (Pty) Ltd include but are not limited to the invoicing, payment allocations and follow up on overdue accounts.

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.

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 CK AUDIOLOGY AND SPEECH THERAPY T/A Hearing Works Blue Route.