We need this information in terms of section 13 of the National Health Act, 61 of 2003, read with the HPCSA ethical rules applicable.
We need this information in terms of section 59(1) of the Medical Schemes Act, 131 of 1998, read with regulation
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
Request for access to records form
Outcome of request and of fees payable form
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