I, the undersigned, grant Ian Hartley permission to treat myself or legal guard in his capacity as a counselling 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.

I understand that Ian Hartley takes the privacy of his patients very seriously and has implemented reasonable security measures to guard against the unauthorised disclosure of private patient information. This document constitutes a contractual agreement with the practice to protect all personal information in confidence.

Ian Hartley will only use a patient’s information in relation to providing healthcare, which means that we may also use the information when we interact with you Medical Aid or when processing your account.

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. In the event of a third-party request for confidential information from Ian Hartley, and in doubt of regarding the safety of confidentiality processes, Ian Hartley may insist on the following processed stated in the Promotion of Access to Information Act (PAIA). Requests for access to information kept by Ian Hartley can be lodged with the Information Officer.

I understand that Ian Hartley’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. I have been informed that Ian Hartley may not charge the specific rates that my Medical Scheme will reimburse in full. The terms and tariffs applicable to Medical Scheme vary from scheme to scheme, and from option to option (plan to plan). I accept that it is my responsibility to obtain those details from my scheme.

Consultation fees are payable at the end of each session via cash or EFT, unless alternative arrangements have been agreed on. I accept that I am fully responsible for payment of the services rendered and should I fail to make payment timeously, I have been informed that my account may be handed over to a debt collections agency or attorney for recovery of the outstanding amount. I consent to the sharing of my personal data with the third party collections agency or attorney for the purpose of collecting any outstanding amount.

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.

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 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 I am liable for the payment of all accounts should my medical aid scheme fail to settle a claim for any reason.

I understand that Ian Hartley 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 session. I understand that my medical aid will not cover the cost of missed or cancelled appointments. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Ian Hartley serve as a courtesy and have no bearing on the confirmation of an appointment.

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.

INFORMED CONSENT: PROCESSING OF PERSONAL INFORMATION

Appointments are recorded using your initials and/or first name on a password-protected electronic calendar 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 safeguards 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.

I utilize smeMetrics Practice Management Software to manage bookings, create invoices and make claims. They are a reputable company with strict privacy guidelines

I understand that this practice makes use of Kitrin (Pty) Ltd to manage all administration aspects of the practice including but not limited to invoice submission through smeMetrics, unpaids management and medical aid follow ups.

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
I confirm that I have read and understood each of the terms and conditions contained in this document and understand that this document constitutes a part of the terms and conditions under which the professional services will be rendered.

I acknowledge that I am signing these terms and conditions voluntarily without being forced, influenced or pressured to do so. I have been given the opportunity to ask questions prior to having signed this agreement.