Kitrin

Your Growth is Our Business

I, the undersigned, grant Marti Simpson permission to treat myself or legal guard in her capacity as an occupational Therapist. I hereby give permission to the therapist to interview, assess and treat me/ my legal guard according to the guidelines and terms mentioned below

Consent to Occupational Therapy Services

I the undersigned understand that :

It is important that I give the most accurate health history and information and that Simpson Occupational Therapy Inc. and any therapist in its employ will not be held liable for any damages should I fail to disclose any information.

The a) purpose of assessment and treatment, b) procedures, c) modalities, d) the associated benefits and risks, e) alternative options and f) what would be expected of me during the treatment period (e.g. therapy duration, importance of keeping to the whole program, client co-operation, practice at home, etc.) will be verbally explained to me on an ongoing basis during sessions and my verbal consent will be documented in my treatment notes.

I am free and encouraged to ask any questions regarding the proposed management.

The occupational therapist will be performing the relevant safety tests and taking relevant precautions.

During treatment and evaluation sessions I might need to uncover specific body parts and I understand that I may refuse to do so.

It is my right to decline treatment offered at any time; this will be noted in my therapy notes.

It is my right to request a second opinion.

The therapist reserves the right to deliver occupational therapy services for good cause shown in which case I will be referred to another therapist which referral I may accept or decline.

If I am running more than 15 minutes late for a session the Practice could reschedule my appointment and charge a fee for a missed session.

Appointments need to be rescheduled at least 2 hours before the scheduled time; the Practice may charge a fee for missed appointments if the Client refrains from doing so.

Fees for missed appointments are not covered by the medical aid.

Confidentiality :

Personal information includes but is not limited to information that identifies me, my address, contact and billing details and medical history and condition.

I the undersigned hereby acknowledge that the Practice deals with personal information in the following way:

  1. Simpson Occupational Therapy Inc. (the Practice) requires your personal information for the following purposes:
    • To determine the best assessment and treatment practices, in which case your information may be shared with your treatment team.
    • For account purposes: The Practice makes use of an outsourced billing company (Kitrin) who has electronic access to personal information relevant to billing (including ICD 10 codes and treatment codes). This information may be processed and shared with your medical aid for billing purposes on by means of the SMetrics software.
  2. The Practice collects and stores personal information in various formats including but not limited to written hard copies, electronic copies; photographic, video, sound recordings:
    • Information required for billing and consent can be collected in writing or electronically.
    • Clinical assessment and treatment notes can be captured in writing or electronically.
  3. The Practice safeguards your personal information as follows:
    • Hard copies: Stored in a locked cupboard within an armed building.
    • Electronic copies: The drive used to store information is password protected; the devices used to access electronic copies is equipped with an anti-virus and password protected.
  4. In the case of a data breach the Practice will notify affected individuals.
  5. Destruction of personal information:
    • The Practice destroys personal information as follows: Shredding of hard copies; deletion of electronic copies.
    • Timeframes: Documents will be stored up to 6 years after becoming dormant; minor information will be stored until they are 21 years old; documents of individuals’ who are mentally impaired will be stored for the duration of their lifetime.
  6. Communication with the practice must preferably be done telephonically or via email:
    • WhatsApp has risks and if a client chooses to communicate via WhatsApp the client consents to this risk.

Billing Consent:

All occupational therapy services are rendered subject to the following agreement to settle accounts:

It is the responsibility of the Client and Debtor to provide information that is true and correct.

This contract is between the Practice and the Debtor who assumes responsibility for the Occupational Therapy account of the above Client in all instances.

The Client or Debtor can request a written quotation of estimated fees prior to commencing therapy.

This Practice charges fees in line with medical aid guidelines (the list of fees can be viewed on request).

Estimated fees and options will be discussed upfront with the Client and Debtor.

The fees charged per session can be made up out of various components which includes; but are not limited to the following:

  1. The duration of the session is at an average of R124 per 15 minutes (dependent on medical aid).
  2. Screening and evaluation procedures (will be discussed upfront if required).
  3. Fees to fabricate splints & pressure garments (fees will be discussed prior to offering this service).
  4. Cost of material used during therapy sessions (This aspect will not be covered by your medical aid and will be discussed with you prior to issuing).

The Practice reserves the right to charge for missed appointments. Appointments need to be rescheduled at least 2 hours before the scheduled session.

If an account is not settled within 30 days of date of invoice or statement the Practice may reserve the right to terminate therapy services; the account will then be handed over for debt collection and the debtor will be liable for legal costs on attorney and own client scale and collection commission.

Services rendered OUT of Hospital:

Out of hospital therapy sessions must be paid in cash. The Practice will provide an invoice which the debtor may submit to the medical aid to request a reimbursement.

The Practice may elect to submit claims directly to the medical aid provided the debtor:

  1. Can provide proof of available funds (savings) with the assigned medical aid.
  2. Can provide proof of authorized Prescribed Minimum Benefits (PMB) for Occupational Therapy services.
  3. The debtor will be liable to pay the difference between the payment made by the medical aid and the account due, within 30 days of statement.

The cost of material for Splints, Pressure Garments, Therapeutic Equipment and similar items has to be settled in cash on the day of being issued therewith as medical aids won’t cover these expenses.

If the Practice elects to submit accounts to the medical aid service provider it does not absolve the Debtor from payment. If the medical aid rejects the claim for any reason the Debtor will be liable to settle the account within 30 days of date of invoice or statement. The Practice will not be responsible if the medical aid refuses to accept the ascribed ICD10 codes and treatment codes.

Services rendered IN the Hospital:

The Practice will submit all in-hospital accounts/claims directly to the medical aid. In doing so it does not absolve the Debtor from payment. The Debtor is solely responsible to see to it that the account is settled via cash or through the medical aid provider. The Practice will not act as an intermediary between the Debtor and the medical aid provider.

The cost of material for Splints, Pressure Garments, Therapeutic Equipment does not get covered by the medical aid and has to be settled in cash with the Practice within a week of being discharged (this will be discussed prior to being issued).

If the medical aid rejects the claim for any reason the Debtor will be liable to settle the account within 30 days of date of invoice or statement.

The Practice will not be responsible if the medical aid refuses to accept the ascribed ICD10 codes and treatment codes.

I the undersigned confirm that the billing procedures have been discussed and understands the terms and conditions thereof and that the contract is signed freely and voluntarily without duress.

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 Marti Simpson.