Withdrawal of Consent

I the undersigned do hereby withdraw my consent from the below listed practice to use my information in regards to the processes indicated below. I request that the below listed practice remove my information from their systems in accordance with the The Protection of Personal Information Act (POPIA).

I understand that, should my medical aid or any medical professional need access to this information from the below practice that it will no longer be available as I have requested that it be deleted and destroyed and I accept any and all liability with regard to this request.

Name of Person Withdrawing Consent *

First

Last

Email of Person Withdrawing Consent *

Mobile Number of Person Withdrawing Consent *

Details of Healthcare Provider *

Name of the healthcare practitioner treating yourself or your legal guard.

I hereby revoke the right in terms of the Protection of Personal Information Act (POPIA) for any of my information to be used going forward for the below activities. *

Appointment Scheduling
Accounts Management
Medical Aid Submissions

Reason for the withdrawal of consent *

I understand that my withdrawl of consent may result in treatment being suspended *

Yes
No

I confirm that my personal information is to be removed from the practice's billing software *

Yes
No

I understand that by law the practitioner has to retain all medical information for a minimum of 10 years and that this information cannot be deleted *

Yes
No

I understand that by withdrawing my consent the practice will no longer be able to submit claims on my behalf to my medical aid scheme *

Yes
No

I understand that I will remain liable for any and all outstanding accounts and that the practice reserves to the right to hand my account over for collection. *

I understand
I do not understand

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