Client Consent Form and Contract :: Keri-Anne Hacker

I, the undersigned, grant Keri-Anne Hacker permission to treat myself or legal guard in her capacity as a physiotherapist. I accept that she does not do assessments or reports for legal purposes.

I, the undersigned, understand that Keri-Anne Hacker is a physiotherapist and is registered with the HPCSA. Keri-Anne Hacker will explain the therapeutic process to me and I understand that I have the right to withdraw at any time. I accept that consultations are recorded. I accept that information regarding my therapy may be communicated for referrals and supervision/consultation procedures. My information will remain confidential, however I understand that there are limits to confidentiality, including: should I be a risk to myself or others; when a child is in danger; if the court orders Keri-Anne Hacker to reveal my information. Information can be used for research purposes provided my anonymity is assured.

For the convenience of the children requiring regular therapy, the practice provides weekly accounts on a Friday.

These accounts are emailed to you or on requested, directed to your medical aid. Keri Hacker does not have a contact with the medical aids; therefore ultimately you are responsible for payment of the account should your medical aid not cover the claims.

Treatment will cease should your account be outstanding for longer than 60 days. Accounts which are not paid after 90 days will be handed over for debt collection with the possibility of your being blacklised. You will also be liable for any and all legal costs, including attorney and own client costs as well as collection charges once your account is handed over.

Please be aware that unfortunately Keri Hacker cannot grant discounts as this is against that Health Professional Council’s policy.

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.

Please note that you remain liable for payment of claims submitted to the medical aid in the event that the scheme does not pay the claim
Please note that your medical aid may reject the claim if the diagnosis code is not submitted
eg. Meningitis, convulsions, ect
Eg :: Illness, accidents, stress etc
If yes please specify
If yes please specify
If yes please specify
If yes please specify the type of therapy and the name of the therapists
Eg :: playball, swimming, karate, etc



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 Keri-Anne Hacker.