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.
As per outstanding invoices processed by July Masango.