PATIENT TERMS AND CONDITIONS

THIS IS A LEGALLY BINDING AGREEMENT between: Dr Nico van Helsdingen HPCSA Number: MP 0551163 and

(Please fill in Name and ID Number)

Please read this agreement carefully, and do NOT sign this agreement unless you fully AGREE TO and UNDERSTAND these terms and conditions.

INFORMED CONSENT

I understand that I have the right to ask my doctor to explain and disclose the following medical information to me before I agree to a medical procedure or treatment:

• The different diagnostic and treatment options generally available to me
• Common and serious side effects of a specific treatment option
• The benefits, risks, costs and consequences associated with each option
• The diagnosis and prognosis, and the likely prognosis if the condition is left untreated
• Any uncertainties regarding the diagnosis or the fact that the treatment is experimental
• How and when my condition and any side effects will be monitored or re-assessed
• The name of the doctor who will have overall responsibility for the treatment
• Whether students will be involved, and the extent of their involvement
• That I have the right to seek a second opinion at any time

GENERIC MEDICINE

I understand and acknowledge that:

• My Medical Scheme may insist that I substitute medicine that appear on my prescription with its generic equivalent
• No substitution may take place in stances where the doctor has indicated (written) ‘no generic substitution’ on my prescription
• It is within my doctor’s sole discretion whether or not to allow for the generic substitution of my medicine

DISCLOSURE OF MEDICAL INFORMATION

I hereby authorise:

• The use and disclosure of my medical information to any relevant specialist as my primary doctor may see fit
• That a copy of my medical record will be kept by my doctor on file
• The processing, use and storage of my medical information as may be necessary in the circumstances
• The disclosure of relevant medical information to my Medical Aid. This type of information will typically include my diagnosis and my ICD-10 diagnostic code

PRIVACY OF MEDICAL INFORMATION

I understand and acknowledge that:

• This practice takes the privacy of its patient very seriously and has implemented reasonable security measures to guard against the unauthorised disclosure of my patient information. That the practice will regard my information as confidential in relation to my healthcare, however, may need to disclose this to other healthcare providers with regards to my treatment to which I consent
• I may revoke my authorisation in writing at any time
• my medical information will not be disclosed to unauthorised persons
• my patient information may be disclosed by this practice in response to a specific request by a law enforcement agency, subpoena, court order, or as required by law. That I authorise and give consent to the Practice, the staff or agent of the Practice, which may include the practice management services of a contracted third party, to present for payment all the relevant details and personal information, on my behalf to the medical scheme, managed health care organisation or insurer, owed to the Practice. That this information will include a diagnostic code (ICD-10) or other details relating to the treatment. Notwithstanding the aforesaid, I acknowledge that it remains my duty to ensure that all accounts are received by the medical scheme timeously. The Practice, nor its agents, shall incur any liability in instances where accounts are not submitted to the medical scheme timeously

PAYMENT OF MEDICAL COSTS

I acknowledge that:

• I have been informed that this practice does not charge the rate that my Medical Aid may have decided upon
• My Medical Aid and plan of choice may or may not cover all the fees charged by this practice (for more information regarding which benefits your chosen medical aid plan includes and/or excludes please contact you Medical Scheme)
• I have been informed that this practice charges above the % as per the market leader (for more information on the rates we charge for specific services, please contact our rooms at 021-851 1357.
• I am aware that the values for services are available from my Medical Aid according to the option I have chosen
• I am fully responsible for payment for services rendered and should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale. I consent that should this be the case, my personal information may be given to the debt collection agency / attorneys.
• This practice do PMB and chronic registrations at a fee not necessarily payable by your medical aid. If you do not want to make use of this service please inform us accordingly.

PRE-AUTHORISATION

I am fully aware of the fact that if a procedure requires hospitalisation:

• I am responsible to ensure that my Medical Aid covers the financial costs of the procedure BEFORE I undergo the procedure
• My Medical Aid would generally contact my doctor to discuss the appropriateness of the procedure or to ask him for a motivation for the procedure
• That my doctor may discuss the appropriateness of the procedure or motivation for the procedure with my Medical Aid

MEDICAL CERTIFICATES (“SICK NOTE”)

I hereby acknowledge that I understand that:

• Although I am entitled to ask for a medical certificate from my doctor, he/she is under no obligation to issue such a certificate
• My diagnosis will be disclosed and the decision who I want to show the certificate to is in my sole decision

GENERAL

I hereby conform that:

• I have freely chosen this practice to consult with
• I am aware of the fact that the availability of my doctor is generally limited to office hours and consulting times
• I have had an opportunity to review these terms and conditions and that this form accurately reflects my wishes
• I have been made aware of any potential conflicts of interest my doctor may have
• I have read and understand each of the terms and conditions in this agreement
• I am aware of the fact that I am entitled to request this practice to translate this document into one of the relevant official languages
• I am signing these terms and conditions voluntarily without being forced, influenced, pressured or harassed to do so.

I hereby understand that:

• My doctor has the right to change his mind about a medical decision at any time
• I am under the obligation to inform the practice of any relevant changes to my personal, medical and/or financial information
• I am under no obligation to sign this form
• I have a right to inspect and/or copy these terms and conditions, and my medical file in the practice