Telehealth Consent Form Functional Minds OT
THERAPY AND CANCELLATIONS
Therapy will take place in the form of “telehealth”. We would like to offer you the option of participating in digital online therapy sessions via an online portal called Zoom/Skype. Please note these sessions will be documented as digital sessions and billed accordingly to the intervention given. Therapy will be provided by Mandy Mitchell or other Occupational Therapists employed by Mandy Mitchell.
Please note occupational therapy is not compulsory, and the patient can refuse treatment at any time. For group sessions (where applicable) you indicate that: You understand that you will be part of a group. You can raise your concern at any time, and you can refuse to participate if you feel your confidentiality is not respected/ensured.
You also understand that you must keep the information shared by others in the strictest of confidence. If you are willing to consent to this intervention, please can we request your written consent to proceed with booking these sessions? If you wish a family member, caregiver, parent or another person to be present during the session, we also require your written consent to that.
In the case that the patient needs to cancel a standing appointment for treatment from the occupational therapist, the cancellation must be done 24 hours in advance. If less than 24 hours notice is given by the patient or the person responsible for the account for the cancellation of the appointment the full treatment fee will be charged.
PAYMENT OF ACCOUNTS
It is important to note that the account for services rendered by Mandy Mitchell Occupational Therapy will be your responsibility to settle. Payment terms are 30 days, after which interest will be charged on
accounts outstanding longer than 30 days. The interest is directly payable by the patient. Therapy will be discontinued on accounts outstanding longer than 60 days, and these accounts will be handed over to an attorney without further notice.
In the event of any legal actions taken against me, you consent to the Magistrates Courts Jurisdiction for all accounts instituted against you. The person signing the terms and conditions of service document will be responsible for the payments of any costs, as on attorney and client scale, incurred by the attorneys and the practice in collecting the outstanding amounts. Where payments are made directly into the practice account or via Internet banking, proof of payment must be mailed or delivered to the practice on the day of payment.
ACCOUNTS AND TARIFFS
Any changes to personal details must be submitted to the practice in writing. The person responsible for the account, as indicated above, will be expected to pay the amount in full. In these cases, the person that signs the terms and conditions form will be fully responsible for the payment of the account
The patient’s information will be treated as confidential and will not be shared without written permission from the patient.
COMPLIANCE WITH THE PROTECTION OF PERSONAL INFORMATION ACT (POPIA)
I understand that this practice takes the privacy of its patients very seriously and has implemented reasonable security measures to guard against the unauthorised disclosure of my private patient information.
This document constitutes a contractual agreement with the practice to protect all personal information in confidence. We will use the patient’s information only in relation to providing healthcare, which means that we may also use the information when we interact with your Medical Aid or when processing your account.
I confirm that all information supplied by myself is true and correct and that I am responsible for updating my information to ensure that it is correct and for not providing any false information.
I acknowledge that my personal and special personal information will be kept for the required storage and retention periods according to and in line with legislation periods applicable to the practice and the medical/healthcare industry.
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 processes stated in the Promotion of Access to Information Act (PAIA). Requests for access to information kept by the practice can be lodged with the Information Officer of the practice.
I acknowledge that my patient information may be disclosed by the practice in response to a specific request by a law enforcement agency, subpoena, court order, or as required by law.
I accept that clinical information obtained in sessions may be used for research purposes, presented anonymously at professional meetings and/or published in journals or textbooks. I understand that at no time will any identifying information be used and that I may object to my de-identified information being used in any circumstances. If the conditions are not adhered to, the practice will be forced to discontinue therapy.