Dr Nico van Helsdingen: Patient Information Form

Patient Information

We need this information in terms of section 13 of the National Health Act, 61 of 2003, read with the HPCSA ethical rules applicable.

Next of Kin

If not the same Person/Member liable for payment if not the same as above:

We need this information in terms of section 59(1) of the Medical Schemes Act, 131 of 1998, read with regulation

Medical Aid Particulars:

Referring Doctor/Optometrist

I, the undersigned, hereby declare that all the above-mentioned information is just and true. I accept all responsibility for payment of the full outstanding amount, if not settled by my medical aid/-scheme within 60 days and for payment of any legal expenses due to nonpayment of any accounts on attorney and client scale. I declare that I was informed that my medical aid/-scheme might require personal information with regards to my account from time to time and I grant the necessary permission that the requested information can be send to the medical aid/-scheme in order to assure/speed-up the payment of my account. I take note that Dr NT van Helsdingen does not charge according to scale and that I will be responsible for the outstanding balance. Information supplied can be used for account purposes.