Client Consent Form :: Masango Occupational Therapy
I, the undersigned, grant July Masango and his staff at Masango Occupational Therapy permission to treat myself or legal guard in his capacity as an Occupational Therapist. 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 Masango Occupational Therapy’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.
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.
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 Masango Occupational Therapy 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 accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Masango Occupational Therapy serve as a courtesy and have no bearing on the confirmation of an appointment.
Any sessions/consultations with third parties will be charged to the undersigned, even if at the request of Masango Occupational Therapy. 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 billing software called smeMetrics, all invoices will be sent to myself or my scheme using this software.
I understand that this practices makes use of Kitrin (Pty) Ltd to manage all administration aspects of the practice including 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.
As per outstanding invoices processed by July Masango.