Informed Consent and Tariff Information
Please assist us in making your experience at the practice as enjoyable as we strive for it to be by reading and ensuring you clearly understand the information below. By signing this form you confirm that you understand your/your child’s treatment at this practice, the rates involved and the requirements involved in settling the account.
1 : Informed Consent
Informed consent for children under the age of 12 must be signed by the parent and/or guardian. Children above the age of 12 who show an understanding of the below discussion and comprehend the nature and scope of it, have to sign the informed consent form themselves.
I hereby give permission for the execution of the following treatment, namely:
.1. Developmental Ax and Rx: Full assessment of gross and fine motor skills, including balance, co-ordination, muscle strength, motor planning and development as appropriate. Treatment will include an individualised programme based on the areas of difficulty found in the assessment.
AND/OR
.2. Respiratory Ax and Rx: Assess the child and treat the respiratory complications as necessary including the appropriate chest physiotherapy techniques (percussions, vibrations, nebulisation, breathing exercises) as appropriate. Suctioning will only be done if indicated.
I also give permission that the planned treatment may be adapted during the execution of it if proven therapeutically necessary.
2 : Rates
2.1 Notice is hereby given to the patient and relevant parties that tariffs raised by Lara Berman Physiotherapy are not necessarily the same and also do not have the same rand value as my relevant medical aid. Although Lara Berman Physiotherapy tries its best to stay within medical aid rates.
2.2 FULL payment of the account remains the responsibility of the parent/main member; regardless of whether the medical aid covers only a portion of the costs. The initial assessment must be settled directly by the parent/main member with the practice, afterwhich Lara Berman Physiotherapy will submit the account directly to medical aid for subsequent treatment sessions on the patient’s behalf, however I still remain responsible for the account until it is paid in full. If I fail to pay the costs in full within 30 (THIRTY) days of treatment, I will forthwith also be held responsible for any debt collection fees incurred by the practice or debt collector.
Please note this practice claims directly from medical aid. However, it is still up to the parent/main member to settle the account in full with the practice if there is a shortfall payment from the medical aid OR if your medical savings is depleted and/or if the payment is rejected OR if you are on a Hospital Plan only. Thank you.
2.3 The practice at its sole discretion has the right to terminate non-emergency treatment due to non-payment of accounts.
2.4 It remains my own responsibility to familiarise myself with the specific coverage of my medical insurer, as medical aids and plan types differ.
2.5 The practice will submit the account to my medical aid on the patient’s behalf. Notice is also given that diagnostic information must appear on the statement to the medical aid. If this is omitted, the fund will fail to make payment.
2.6 I hereby also declare that if I am not personally the main member of the medical aid, he/she has been made aware that the account will be submitted directly to the medical aid for payment.
2.7 Rates for 2021: The assessment will be R1 113.00 and a 35-40 minute treatment session will be R 668.00. If a report is requested this will be R 650.00 which is not covered by medical aid. There is an increase in January each year in line with medical aid increases.
3. Invoicing and Administration
This practice makes use of smeMetrics Practice Management Software to manage bookings, create invoices and make claims. They are a reputable company with strict privacy guidelines.
4. Cancellation Policy
Appointments should be cancelled telephonically 12 hours before the date and time of the appointment.
The full consultation fee will be charged for appointments not kept or not cancelled timeously. This is not payable by the medical aid, but the parent/main member remains responsible for settlement of this.
5. Indemnity
I indemnify and hold harmless the therapist and their employees from all liability of whatsoever nature for loss/damages which may be suffered by myself and/or my children; howsoever such a loss/damage may occur whilst on or outside the premises of the therapist. I agree that the use of any apparatus/equipment on the premises by any of my children is entirely at my own risk.
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 Lara Berman Physiotherapy