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Dear Valued Patient,

This document explains the general conditions under which this practice sees
patients. It does not constitute an informed consent to any specific treatment,
nor a quotation or price for any service rendered by the practice. Informed
consent and price information will be provided each time you visit the practice,
and will depend on the care you need/seek, and other factors such as your
medical scheme cover.

This serves as a binding contract between you, the patient, and the above
practitioner. You may only sign on behalf of yourself or your dependents under
the age of 18 years or authorized defendants. For patients on medical scheme
plans and over the age of 18 years but registered as defendants on a medical
scheme plan, an individual signature is required on a separate form as a binding
contract with this practice.

You are obliged to provide your informed consent for any treatment or
procedure performed by the Healthcare Professional. Your rights obligate the
practice to discuss the clinical aspects, financial implications pertaining to your
health status, the diagnostic process as well as the different treatment options
available to you. You have the right to retract your informed consent at any stage
or to refuse such medical care. Should your treatment include a referral to other
healthcare specialists (like a doctor, other allied healthcare professional, etc.),
you are required to provide informed consent to their respective treatment and
professional fee policies. You also hereby provide consent for the exchange of
clinical information between healthcare providers.

Under the provisions of The Children’s Act, children may consent to certain
medical treatment from the age of 12 years. Parents / guardians are however
required by law to cover the expenses incurred for the healthcare of their
children. Healthcare Professionals are obliged to guard the healthcare
information of these children and to keep it confidential and only divulge the
information subject to the child’s consent. Please request the practice
management staff to provide examples of these conditions, should you require
further information.
In the current medical aid market environment, patients are purchasing lower
cost medical aid plans with restrictive limits on treatment with less benefits,
medicine restrictions, limited hospitalization and surgery cover, public hospitals
as providers of pre-determined treatment and surgical procedures, and
restrictions on access to Healthcare Professionals.

Your treatment, financial costs, and quality of your professional care can be
severely affected by the type of medical plan you belong to and the
generalization of statements such as “100% cover” by your medical aid or may
not correspond with all the aspects of treatment you may require. These
limitations often prove problematic for your Healthcare Professional as the right
to obtain the necessary professional medical care that meets an acceptable
standard is being influenced by your choice of medical aid cover. It remains your
primary responsibility to familiarize yourself with the benefits and conditions of
your medical aid plan. It is important that you know your benefit status with
regard to the extent of your health cover, referral restrictions, savings account
balances, registration and pre-authorization processes, waiting periods and
other requirements. The Medical Schemes Act 131 of 1998 and its regulations
entitle members of a medical scheme to all information on their benefits and
limitations of their plan. You are responsible to acquaint yourself with the
benefits, insured rates and terms and conditions of your medical scheme plan.
Practice Details:

Ascertain the exact amounts your scheme provides for in terms of consultations,
procedures, treatments as well as what your medical aid will pay and not pay for.
Where a Designated Service Provider has been appointed by your medical aid, it
remains your responsibility to be cognizant of this and to bear responsibility for
any restrictions that may follow (either medically or financially) when consulting
a non-designated Healthcare Professional.

With ever increasing intervention from your medical scheme, please be aware
that this practice will not allow a medical scheme to violate the Healthcare
Professional’s professional and clinical independence.

Where a medical aid or its advisors intervene to overrule your Healthcare
Professionals preferred diagnostic approach or treatment, your Healthcare
Professional assumes no responsibility for consequent adverse outcomes. You
may be asked to assume responsibility by the medical aid and its medical advisors
in the event of complications.

If pre authorization is required for any intervention or treatment, it remains your
responsibility to ensure that the planned treatment is covered by your medical
aid and that the necessary finances are put in place to cover the non-insured
costs. It also remains your responsibility to furnish the practice with the relevant
information and authorization numbers. The practice may assist you in this
process dependant on the individual practice policy. Where your medical aid
questions any aspect of your treatment, your Healthcare Professional may
submit a letter of motivation to the medical scheme if appropriate and may also
insist on a peer-to-peer discussion in above instances.

To avoid misunderstanding regarding payment policies and to maintain the
professional healthcare standards of this practice, you will be informed of the
current payment options and policies available in the practice. These fees are
determined based upon the appropriateness of the quality and standard of
services rendered. No accounts will be rendered for services not delivered or
delivered to someone else. The practice personnel can inform you if the practice
has an agreed policy in place with your medical scheme, at your request.
This practice reserves the right to claim directly from you in which case you will
be provided with a detailed invoice that is payable to the practice within 30 days
from date of service. You have the prerogative to claim this back from your
medical aid. This practice submits accounts subject to the National Credit Act,
The Consumer Protection Act, the Medical Schemes Act, Protection of Personal
Information Act (POPI) and the guidelines as published by the HPCSA.
This practice reserves the right to charge a service fee for any credit given in
terms of the provisions of the National Credit Act, Act No. 34 of 2005. In terms of
section 101 (1) (c), an initial per transaction service fee may be charged on the
transactions for which a credit amount is provided and thereafter on a monthly
basis for each month a credit balance remains. In terms of section 101(1)(d),
interest may be charged on the account for each month the credit amount is not
paid by you. Where legal action is instigated for the recuperation of costs for
services rendered or goods provided in terms and associated with the rendered
service by this practice then in terms of section 101 (1) (g) collection costs may
be imposed to the extent permitted by Part C of Chapter 6 of the National Credit
Act, Act no 34 of 2005.

Version 1
Shamim Khan Physiotherapist
© Copyright – ProfNet: 7 November 2014 Shamim Khan Physiotherapist | 7227108 | Berea
Shamim Khan
Shamim Khan Physiotherapist
399 Clark Road, Berea, Durban

You will be informed of the practice billing policy and the prices for services
generally rendered by the practice, should you request it. Where an exact price
cannot be presented, a quotation aligned with these applicable laws will be
provided, subject to its own terms and conditions. This will be discussed with
you at every visit or treatment event to the practice. Due to the billing policy of
the practice and the fee your medical aid is reimbursing at, a co-payment may
have to be levied by the medical aid or the practice.
You (or your parent/guardian) remain at all times liable for the account for
services rendered by this practice even if you are insured by a medical aid or
other third party. This agreement does not preclude the practice from taking all
reasonable and practical steps to recover any outstanding amounts. The practice,
as mentioned earlier, reserves the right to charge interest on your outstanding
accounts due from date of service up to maximum interest allowed for in terms
of section 2 of the Prescribed Rate of Interest Act.
It remains your responsibility to inform and update all personal and medical aid
detail information with the practice and to keep the practice regularly informed
with regards with any changes on your contact details, benefits and list of
dependants. Please note that the use of someone else’s medical aid card with or
without such a person’s consent or knowledge constitutes fraud. This practice
will report such instances to the medical aid concerned to protect the practice
from being regarded as a cooperative in the fraud.
This practice will only provide sick certificates should the specific condition so
warrant. If a diagnosis is provided on the sick certificate, the certificate will only
be handed or faxed to you unless otherwise requested by you in writing. It
remains your discretion to disclose your condition or diagnosis to your employer.
If you or your employer is considering claiming for a disability, you may be
required to disclose the nature and extent of such a disability to your employer
and insurance company.
All information handled by this practice is regarded and treated as strictly
confidential by the Healthcare Professional and the practice staff. Should you
belong to a medical aid and the medical aid forwards such an account to the
principle member of the medical aid, confidentiality may be compromised as
legislation compels this practice to provide certain information to the medical aid
on the accounts. Failure to submit the correct codes might lead to the claim being
incorrectly paid or not paid at all. Regulation 5(f) of the Medical Schemes Act
(published in the Government Gazette No 20556 on October 20th, 1999) states
that an account to a medical aid must contain the relevant diagnosis.
This must be submitted as an ICD-10 diagnostic code. It has become necessary to
disclose these ICD-10 codes on referral letters, requests for special investigations
(e.g. radiology, pathology) etc.
In the event that a practice or its administrator approaches this practice with a
request for confidential information and uncertainty exists over the soundness
of the required confidentiality processes that has to be in place, the Healthcare
Professional will insist to follow the standard operating procedures as legislated
in the Promotion of Access to Information Act and its equivalent Acts or rules.
Your de-identified information may be used for epidemiological, research or
practice business planning and may be passed on in a de-identified format to 3rd
parties for further processing. For accurate health care planning, it is important
that adequate information is included in these types of analyses. Your
participation in this regard is highly appreciated.

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