Client consent and contact for Masango Occupational Therapy

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Informed Consent Form :: Masango Occupational Therapy

I, the undersigned, grant July Masango and his staff at Masango Occupational Therapy including but not limited to Este’ Roberts and Laura Pakendorf permission to treat myself or legal guard in their capacity as an Occupational Therapists. 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 that all information given to Evexia Day Clinic for my stay will be provided to Masango Occupational Therapy for billing purposes for any occupational therapy sessions that I attend while at Evexia.

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.

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 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.

Name *

First

Last

ID Number *

Email *

Contact Number *

Residential Address

Medical Aid Name *

Membership Number *

Name and Surname of Main Member *

I the undersigned consent to treatment from Masango Occupational Therapy *

Yes
No

I the undersigned have read and understood that the practice of Masango Occupational Therapy uses Kitrin (PTY) Ltd for all administrative functions of the practice *

Yes
No

I the undersigned have read and understood that the practice of Masango Occupational Therapy uses smeMetrics billing software for the processing of invoices *

Yes
No

I understand that all information provided to Masango Occupational Therapy by Evexia Day Clinic will be provided to Kitrin (PTY) Ltd for billing and accounting purposes *

Yes
No

i the undersigned acknowledge that I remain liable for payment of my account should my medical aid not settle the claims *

Yes
No

CONTRACT TERMS

PRICING
As per outstanding invoices processed by July Masango.

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 July Masango.

Contact Information