- Acknowledge that I have been informed that this practice does not charge the rates that the Department of Health has unilaterally determined for doctors and which are known as the Reference Price List (“RPL”);
- Confirm that I am aware that fees charged by this practice fees can be up to 3 times the RPL;
- Confirm that I am aware that the RPL prices for services are available from the Department of Health (Tel: 012-312-0000) and the Health Professions Council of South Africa (Tel: 012-338-9300) and www.doh.gov.za;
- Accept that although I am a member of a medical scheme, I remain fully responsible for payment of the doctor’s account until fully paid;
- Acknowledge that the fees charged by the practice may be different to the benefit to be paid by my medical aid / scheme, and I accept responsibility for any co-payment resulting from any difference between these two amounts;
- The fact that the practice may submit a claim to the medical aid / scheme, Compensation Commissioner, Road Accident Fund or an insurer, will not in any way relieve me of my liabilities as aforesaid;
- Confirm that, should I not pay timeously, I will be liable for payment of legal fees incurred by the practice in recovering any amount due (including but not limited to tracking costs and collection fees) on attorney and own client scale;
- Acknowledge that the doctor reserves the right to charge for all follow-up consultations post-operatively, irrespective of whether it is in the rooms, the ward, high care or the intensive care unit.
I, the undersigned, do hereby:
Liability for payment
Medical Scheme Benefit
- Warrant that, as indicated, I and / or the patient is a current, paid-up member or dependent of such member under the medical aid / scheme, the patient has not resigned and that the services have not been terminated;
- Authorise the practice to submit the account to the relevant medical aid / scheme for payment on behalf of the patient;
- Give permission for the use of ICD-10 codes, for more effective account payment by the medical scheme;
- Undertake to:
- Ensure that accounts are received by the medical aid / scheme and paid within 90 days of service. I acknowledge that an account older than 3 months will not be settled by the medical aid / scheme and I will be held responsible for the settlement of the account.
- Settle the account within 30 days in case of non-payment or short payment by the medical aid / scheme.
- Acknowledge that pre-authorisation for treatment / services does not guarantee payment by the medical aid / scheme, and that it remains my responsibility to obtain such authorisation if required by my medical aid / scheme.
Disclosure of medical information
- Authorise the practice to disclose to the medical aid / scheme or the Compensation Commission or the Road Accident Fund or insurer to whom a claim has been submitted, in relation to amounts payable to the practice, full details as to the nature, diagnosis, condition, or treatment of the patient.
- Confirm that the responsible person and / or patient has been informed that in certain circumstances, such as disclosure of ICD-10 codes, the exact consequences of disclosing such information are unknown to the practice and that information relating to such consequences, must be obtained by the responsible person and / or the patient from the third party to whom the information is disclosed.
- Confirm that the practice may use the email addresses as indicated in the patient / guarantor details for communication purposes on accounts and / or invoices.
- Agree that invoices and statements shall be posted to me on my request only.
- Undertake to notify the practice of any changes in my indicated domicilium address, contact details or medical aid details.