Client Consent Form and Contract :: Lucas Breedt
I, the undersigned, grant Lucas Breedt permission to treat myself or legal guard in his capacity as a registered podiatrist.
This document explains the general conditions under which this practice sees patients. It does not constitute an informed consent to any specific treatment, nor a quotation or price for any service rendered by the practice. Informed consent and price information can be provided each time you visit the practice, and will depend on the care you need/seek, and other factors such as your medical scheme cover.
This serves as a binding contract between you, the patient, and the practice. You may only sign on behalf of yourself or your dependants under the age of 18 years or authorised dependants. For patients 18 years and older registered as dependants on a medical aid benefit option, a separate patient-practice contract with an individual signature may be required as your binding contract with the practice. Failing the completion of such a separate contract, the signatory of this agreement accepts full responsibility of all beneficiaries on his/her medical aid.
Your Healthcare is important to us
Informed consent would be required by you for any treatment or procedure performed by the Healthcare Professional/s of the practice. The practice is obligated, by your individual rights, to discuss the clinical aspects, financial implications pertaining to your health status, the diagnostic process, as well as the different treatment options available to you. You have the right to withdraw your informed consent at any stage and refuse any advised medical care. Should your treatment include a referral to other Healthcare Professionals you are required to provide informed consent to their respective treatment and professional fee policies. You hereby provide consent for the exchange of clinical information between all relevant or
referred Healthcare Professionals, medical schemes, and their administrators or appointed managed care organisations.
Under the provisions of The Children’s Act, children may consent to certain medical treatment from the age of 12 years. Parents/guardians are however required by law to cover the expenses incurred for the healthcare of their children. Healthcare Professionals should safe-guard any
healthcare information obtained from these children, keep it confidential and only disclose information subject to the child’s consent. Please request the practice management staff to provide examples of these conditions, should you require any further information.
What does your medical aid cover?
In the current medical aid environment, patients may purchase lower cost medical aid benefit options with restrictions on treatment and medicine, fewer benefits, limited hospitalization and restricted surgical cover. In addition, medical aids often appoint public hospitals as their designated service providers.
Your treatment, healthcare cost, and quality of your professional care can be severely affected by the type of medical plan you belong to and the generalisation of statements such as “100% cover” by your medical aid. Often these statements may not correspond with all aspects of treatment you may require. These limitations often prove to be problematic for your Healthcare Professional, as your right to access to acceptable and appropriate medical care and management is often influenced by your choice of medical aid cover.
It remains your responsibility to familiarise yourself with the benefits and terms and conditions associated with your chosen medical aid benefit option. It is important that you know your benefit status with regard to the extent of your healthcare cover. Also ensure that you familiarise yourself with referral restrictions, savings account balances, registration and pre-authorization processes, waiting periods and other requirements. The Medical Schemes Act 131 of 1998 and its regulations entitle members of a medical scheme to comprehensive information on their benefits and
limitations of their plan.
Ascertain the exact amounts your scheme provides for, in terms of consultations, procedures and treatments as well as what your medical aid will cover. Where a designated service provider has been appointed by your medical aid, it remains your responsibility as the patient to familiarise yourself with any medical and financial restrictions when consulting a non-designated service provider.
With increasing interventions from your medical scheme, please be aware that the practice will not allow the medical scheme to violate the Healthcare Professional’s clinical independence. Where a medical aid or its advisors intervene to overrule your Healthcare Professional’s preferred diagnostic approach or treatment, your Healthcare Professional accepts no responsibility for consequent adverse outcomes. You may be requested to allocate responsibility to the medical aid and its medical
advisors in the event of adverse treatment outcomes.
If pre-authorisation is required for any medical procedure or treatment, it remains your responsibility to ensure that the planned treatment is covered by your medical aid. It is also imperative to ensure that the necessary finances are put in place to cover the non-insured costs. It also remains your responsibility to furnish the practice with the relevant information and authorisation numbers. The practice may
assist your with this process, dependent on the individual medical aid’s terms and conditions. Where your medical aid questions any aspect of your treatment, your Healthcare Professional may submit a letter of motivation to the medical aid and insist on a peer-to-peer discussion if appropriate
To avoid confusion regarding payment policies and to maintain the professional healthcare standards of the practice, you can be provided with the current practice payment options and policies. Accounts will not be rendered for services not delivered, neither will accounts be delivered to someone who did not receive the service or someone legally entitled to such account. The practice staff can inform you should the practice have any arrangements in place with your medical aid.
The practice reserves the right to claim directly from you in which case you will be provided with a detailed invoice that is payable within 30 days from date of service. You have the option to claim this back from your medical aid should you wish to do so. The practice actions all accounts subject to the National Credit Act, The Consumer Protection Act, the Medical Schemes Act and the Protection of Personal Information (POPI) Act.
Please note that this practice’s billing policy in relation to costs for services rendered. Where an exact price cannot be presented, a quotation could be provided, subject to its own terms and conditions. Due to the billing policy, a co-payment may be levied by the practice.
You (or your parent/guardian) remain liable for the account at all times, for services rendered by the practice even if you are insured by a medical aid or any other third party. This agreement does not prevent the practice from taking all reasonable and practical steps to recover any outstanding
amounts from any obligated party. The practice reserves the right to charge interest on any outstanding account, in terms of section 2 of the Prescribed Rate of Interest Act.
It remains your responsibility to inform and update all personal and medical aid information with the practice and to keep the practice regularly informed with regard to any changes on your contact details, benefits and list of dependants. Please note the use of someone else’s medical aid card with or without such a person’s consent or knowledge, constitutes fraud. The practice will report such instances to the medical aid concerned to protect the practice from being regarded as a cooperative in committing fraud. The practice reserves the right to charge a service fee for any credit given in terms of the provisions of the National Credit Act, Act No. 34 of 2005. In terms of section 101 (1) (c), an initial service fee per transaction may be charged for each credit amount.
Thereafter this fee may be charged on a monthly basis for each month the credit balance remains. In terms of section 101 (1) (d), interest may be charged on the account for each month the credit amount is not paid by you. Where legal action is instigated for the recovery of costs for services rendered or goods provided, collection costs may be imposed to the extent permitted by Part C of Chapter 6 of the National Credit Act, Act No. 34 of 2005.
The practice will only provide sick certificates should the specific condition warrant such a certificate. If a diagnosis is provided on the sick certificate, the certificate will be handed only to you, unless otherwise specified by you in writing. Discretion in disclosing your condition or diagnosis to your employer remains with you. If you or our employer considers claiming for a disability, you may be required to
disclose the nature and extent of such a disability to your employer, insurance company and/or other third party, where applicable.
All information handled by the practice is regarded and treated as strictly confidential by the Healthcare Professional and the practice staff. Should you belong to a medical aid and the medical aid forwards such an account to the principle member of the medical aid, confidentiality may be compromised. Legislation compels the practice to provide certain information to the medical aid on the accounts. Failure to submit the correct codes might lead to claim being incorrectly paid or rejected. Regulation 5(f) of the Medical Schemes Act (published in the Government Gazette No. 20556 on October 20th, 1999) states that an account to a medical aid must contain the relevant diagnosis.
This must be submitted as an ICD-10 diagnostic code. It has become necessary to disclose these ICD-10 codes on referral letters, requests for special investigations (e.g. radiology, pathology) etc.
In the event of a third party request for confidential information from the practice, and in doubt regarding the safety of confidentiality processes, the practice may insist on following the standard operating procedures legislated in the Promotion of Access to Information Act (PAIA) and/or its
equivalent Acts and rules. Requests for access to information kept by the practice can be lodged to the information officer in accordance with PAIA.
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 paid at private rates, I understand that it is my responsibility to make payment on the date of the therapy session. Lucas Breedt will make available credit and debit card facilities to make this payment process possible.
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. If my account has not been paid for a period of 30 days or more, the full payment will be processed against the authorised bank account. If you’re a medical aid client, a payment on your account will only be processed if the medical aid has not paid the submitted invoice, and it is clearly indicated on the medical aid remittance. You will be notified of this rejection, and of the date that the payment will be processed on your account. The estimated time to get a payment from the medical aid is 4-6 weeks from the date that the invoice is submitted. With all rights reserved, Lucas Breedt has the option to use legal methods to secure payment; this may include a collection agency or small claims court, in which case the cost of such measures will be added to the claim. Notices of outstanding accounts will be served to your residential, postal and work addresses.
I understand that Lucas Breedt may suspend treatment until all outstanding accounts are settled in full.
I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. The debit order authorisation, as completed before, will be used to process payment against your authorised bank account. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Lucas Breedt serve as a courtesy and have no bearing on the confirmation of an appointment.
I acknowledge that phone calls and emails that are longer than 10 minutes will be charged for.
Any sessions/consultations with third parties will be charged to the undersigned, even if at the request of Lucas Breedt. With regard to minors, feedback sessions to parents are charged in full.
I understand that that the email address and mobile number provided 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, 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.
I hereby acknowledge that I have read and understood the above information. I have also been given the opportunity to ask questions prior to having signed this agreement and acknowledge that all information submitted by me is true and correct. I understand that I am under continued obligation to advise the practice/practitioner of any changes that may occur after submission of this contract and acknowledge, by signing this contract, that I am legally bound by the provisions of the contract. This contract is subject to the provisions of the National Credit Act, Protection of Personal Information (POPI) Act and the HPCSA ethical rules. I understand that this contract constitutes a part of the terms and conditions under which professional services will be rendered, in compliance with the Consumer Protection as well as the Protection of Personal Information Act.
The contract terms in terms of the debit order can be found lower on this page, for your reference.
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.
The following are the terms of the debit order for your reference:
This signed Authority and Mandate refers to our contract as dated as on signature hereof (“the Agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our abovementioned account at my/our above mentioned bank (or any other bank or branch to which I/We may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 30 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.
The individual payment instructions so authorised to be issued must be issued and delivered as follows:
Daily; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;
I/We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
I/We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.
As per outstanding invoices processed by Lucas Breedt.
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
I/We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.