PLEASE READ CAREFULLY BELOW THERE ARE 4 DIFFERENT SECTIONS THAT REQUIRE YOUR UNDERSTANDING AND CONSETN

THE SECTIONS INCLUDE

A) ACCOUNT INFORMATION
B) ACCOUNT DECLARATION AND CONSENT
C) TREATMENT INFORMATION
C) TREATMENT DECLARATION AND CONSENT
D) POPPIA INFORMATION
E) POPPIA DECLARATION AND CONSENT

A) ACCOUNT INFORMATION:

PLEASE NOT THAT THIS PRACTICE IS CONTRACTED IN WITH CERTAIN MEDICAL AIDS AND IS STILL UPDATING DETAILS WITH OTHER MEDICAL AIDS. FOR THIS REASON, IT IS AT THE DISCETION OF THE PRACTICE WHETHER WE WILL CLAIM ON YOUR BEHALF, OR INSIST ON THE PATIENT PAYING AFTER THIER CONSULTATION.

In such circumstances where the patient pays cash, The fee is due and payable immediately on completion of the service. The account is rendered directly to you as required by the Medical schemes act No: 131 of 1998.

Upon payment a receipt and invoice will be issued on request to enableto claim a refund from the patients medical fund.

It is the responisbility of the patient or main member to then claim back directly from their medical aid.

The account is rendered completely separate from other medical accounts. The fee is based on the South African Society of Physiotherapy guidelines. (NRPL rates)

In the case of your medical aid not paying the full amount, you will be liable for the balance.

Appointments not cancelled within 3 hours will be charged for. Medical aid schemes do not reimburse you for this amount.

Please note that if payment is not made within 90 days, the account will be handed over to our attorneys for collections. You will be held liable to pay any collection and / or attorney fees on the Attorney Client scale.

It is important that the patient provides accurate and up to date information to the practice about the
patient’s health status, medical history and other personal details such as a valid e-mail address, cellphone number as well as medical scheme membership / other funder information to facilitate appropriate treatment and care of the patient, communication with the patient and payment of accounts.

It is the patient’s esponsibility to inform the practice if any of the information has changed.

B) ACCOUNT DECLARATION AND CONSENT:

I agree to pay the NRPL fee. I understand that I might not be fully reimbursed by my medical aid.

I understand that I remain personally responsible for payment of the account as per this agreement.

I, agree to allow my personal data to be forwarded to the relevant organisations as required by law and to allow anonymous data of a clinical and practice management nature, to be collected to help improve the patient healthcare experience.

I hereby choose my above address as my DOMICILUM CITANDI AT EXECUTANDI for all purposes under this agreement and I agree that any notice sent to the above address by prepaid registered post will be deemed to have been received by me on the third business day after the posting of it.

I further agree that any notice received by me by any means and at any address will be valid for all legal purposes notwithstanding that it was not sent by registered post or to my DOMICILUM CITANDI ET EXECUTANDI.

I agree that should I wish to change my DOMICILUM CITANDI ET EXECUTANDI I will give one week’s prior written notice for such change to become effective.

I also undertake to pay all legal costs on the attorney and own client scale as well as all tracing costs and charges as stipulated by the Debt Collectors Act 114 of 1998 relating to the recovery of fees outstanding on my account in respect of professional services rendered.

I consent to sharing information on my account withy other credit grantors and with the credit bureaux. I agree that the practitioner shall be entitled to charge me all legal costs and disbursements incurred by the practitioner in connection with the appointment of any agents and / or attorneys to recovery any amount owing by me.

C) TREATMENT INFORMATION:

Your Physiotherapy session may consist of the following:

- A planned examination/assessment
- The evaluation, diagnosis, and prognosis/plan
- The intervention/treatment to be provided
- The risks and benefits which may be associated with the intervention
- The anticipated time frames

Potential small but possible risk factors:
-Manual therapy: Joint and/or muscle soreness
-Exercise therapy: Joint and/or muscle soreness
-Electrical modalities: Minor skin irritations such as redness or rash
-Therapeutic Taping: Minor skin irritations such as redness or rash

D) TREATMENT DECLARATION AND CONSENT

I, the undersigned, do hereby give my voluntary consent for the administration of Physiotherapy deemed appropriate by my treating Physiotherapist.

I understand that Physiotherapy treatments may include an individualized exercise prescription and various forms of manual therapy techniques such as mobilization, manipulation, soft tissue release, stretches and exercise rehabilitation.

Treatments may also include modalities such as heat, ice, therapeutic taping, ultrasound, laser, TENS, interferential current, shock wave andelectric muscular stimulation.

I understand that the primary goals of Physiotherapy treatments are to help reduce my pain and improve my mobility, strength, endurance, function and quality of life.

I understand that there are very small possibilities of risks or complications that may result from the above listed treatments.

I do not expect the Physiotherapist to anticipate all the possible risks and complications. I wish to rely on the Physiotherapist to exercise proper judgment during the course of treatment to make decisions based upon my best interest.

I confirm that I have been informed of the purpose of Physiotherapy and I confirm that the risks and complications generally associated with Physiotherapy have been explained to me. I understand the option offered to me and have made my choice.

E) POPIA INFORMATION:

A reference to the patient, includes any person who may consent or contract on behalf of a patient,
and includes the person responsible for payment of the patient’s accounts.

What is Personal Information?

Personal information is defined in the Protection of Personal Information Act [POPIA]) and includes information such as the contact details, age, gender, medical scheme membership and health information.

Collection of Patients’ Personal Information:

Personal information will be collected as far as possible from the patient, but may also be collected from the hospital/facility admission form, other treating practitioners, the patient’s next-of-kin and any other source from which the practice may lawfully collect information (e.g. the public domain / public records), as may be required in the circumstances.

Processing of Patients’ Personal Information:

The practice will only process, which includes collect, use, store and disseminate, the patient and any other relevant person’s personal information in accordance with the law (e.g. the National Health Act, the Medical Schemes Act, the Health Professions Act and POPIA).

The personal information of the patient will be used as follows:

-to provide the patient with appropriate care;
-to communicate with the patient in respect of their care, including reminding the patient
of appointments and collecting payments for services rendered;
-for administrative purposes, including preparing invoices and collecting payment for
services rendered;
-to refer the patient to other practitioners;
-to report to referring practitioners;
-for participation in clinical trials, if applicable;
-record-keeping;
-for historical, statistical and research purposes;
-as proof;
-for enforcement of the practice’s rights;
-for any other lawful purpose related to the activities of a private physiotherapy practice;
and/or
-as may be requested or authorised by the patient.

Records of Patients’ Personal Information:

All personal information will be recorded in the patient’s medical record, which may be held physically or electronically, and which will be retained for such periods as may be prescribed by or permitted in terms of the law and for lawful purposes.

Security:

The practice has implemented mechanisms to ensure that adequate security measures are in place to ensure that personal information will be kept confidential and protected against destruction and unauthorised access. The practice will inform the patient and the Information Regulator, if any person has unlawfully obtained access to his/her personal information, subject to the provisions of the law.

Sharing of Patients’ Personal Information:

The personal information collected before, during and after the provision of the medical services, including full details related to the diagnosis and treatment of the patient (in the form of ICD-10 codes or otherwise), will be shared, as may be appropriate, with other practitioners involved in the patient’s treatment and care, and other persons who may lawfully obtain access to this information such as the patient’s medical scheme, treating practitioners, the patient’s next-ofkin, debt collectors, credit bureaus, regulatory bodies, other public bodies, persons and bodies performing peer review, law enforcement structures and purchasers of the practice. The practice will obtain the patient’s consent for such disclosures, where necessary. Staff members as well as service providers and professional advisers of the practice will obtain access to the information, subject to confidentiality undertakings, and strictly on a need-to-know basis, to provide services and/or advice to the practice. Personal information will not be disclosed by the practice to any person other than those indicated on this form or without the patient’s consent unless authorised in terms of the law. If we must provide the patient’s personal information to any third party in another country, we will obtain prior consent unless the practice may lawfully do so.

Diagnosis / ICD-10 Codes:

The practice must include codes on accounts that disclose the patient’s diagnosis, known as ICD10 codes. These codes are necessary for funding decisions and benefit allocations by funders such as the patient’s medical scheme, the Compensation Commissioner for Occupational Injuries and Diseases and the Road Accident Fund.

Peer Review / Clinical Practice Audits:

The practitioners may be subjected to peer review and the practice to clinical audits from time to time. Bodies performing such peer review or clinical audits may need to obtain access to patient information for this purpose. They will be required to sign confidentiality undertakings and only use the information for the specified purposes, before access is granted.

Access to Patients’ Personal Information:

The patient may have access to his/her personal information held by the practice and may request corrections to it, if required, subject to the provisions of the law. Please enquire at reception and complete the prescribed form. The process is also described in the PAIA Manual of the practice, obtainable from reception or on the practice’s website.

Withdrawal of Consent and Objection to Processing:

Where consent is provided for the processing of personal information, it may be withdrawn at any time. Depending on the circumstances, this may impact on the patient’s continued treatment unless the practice may process the information in terms of the law. If the circumstances make it reasonable and lawful to do so, the practice may terminate its relationship with you. In certain instances, the patient may object to the processing of his/her personal information, if it is reasonable to do so, unless the practice may do so in terms of the law. The objection must be lodged on the prescribed form. Depending on the circumstances, this may impact on the patient’s continued treatment unless the practice may process the information in terms of the law. If the circumstances make it reasonable and lawful to do so, the practice may terminate its relationship with you.

Concerns about the Processing of Patients’ Personal Information:

Should the patient or any other person have any concern or question about the processing of their personal information by the practice, please raise this with any of the treating practitioners. A complaint may also be lodged with the Information Regulator (+27 (0) 10 023 5207 / +27 (0) 82 746 4173 or complaints.IR@justice.gov.za)

E) POPIA DECLARATION AND CONSENT

I confirm that I had an adequate opportunity to read this document and that I fully understand my rights in respect of my information held by the practice and how the practice will process my personal information. I declare that all my questions have been answered satisfactorily. I understand how the practice will process my personal information and with whom it will be shared.

I confirm that I provide consent of my own free will without any undue influence from any person whatsoever. I have received all the information required to provide consent.

I consent to the following specific processing activities of my personal information by the
practice:
a. the submission of my accounts to my medical scheme / other funder
b. the submission of information relevant to my diagnosis and treatment to my medical
scheme / other funder, if required
c. the inclusion of relevant health information in referral letters and when providing
reports about my treatment to referring practitioners or GP
d. to sharing of relevant information with bodies performing peer review of
practitioners or clinical practice audits, subject to confidentiality undertakings

I consent to that the practice may submit my accounts to my medical scheme / other funder and any person/business responsible for payment of the accounts on my behalf.

I consent that my personal information may be used by the practice to bring new products and services to my attention and understand that I may opt out from receiving such marketing communications at any time.