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Patient Information Form

Please complete in full before your session


Person Responsible for Payment of Account


Details of Patient


Payment Method


Medical Aid details


Details of an emergency contact person


Terms and Conditions

1. THE PRACTICE:
The Practice means the social work private practice as described on the turn side of this Form of Admission
.
2. ACCEPTANCE:
The undersigned, patient, responsible person, parent, legal guardian, or surety of the patient, hereby assumes liability as the principal debtor, alternatively as co-debtor jointly and severally with the patient, for the payment of any claims by the Practice arising from services rendered to the patient, or to be rendered to the patient, notwithstanding the existence of a medical aid fund or insurance covering such claims.

3. TERMS OF PAYMENT
Any person who signs this document in any of the capacities described above, confirms that (1) s/he is appraised of the tariffs charged by the Practice (2) s/he will settle the account within 30 days after receipt (3) s/he will notify the Practice within 14 days after the treatment date if he has not received an account.

4. BREACH:
In the event where any of the abovementioned parties commits a breach of contract, the Practice is entitled to take immediate legal action and charge arrears interest at a rate of 15% per year on the outstanding balance from the date of invoice to the date of payment.

5. GENERAL:
This Form of Admission constitutes the whole and entire agreement between the parties and there have not been and there are no agreements, representations or warranties between the parties other than those specifically set forth herein. No variation, modification or cancellation of this agreement shall be of any legal force or effect unless the same shall be confirmed in writing and signed by all parties involved.

6. JURISDICTION:
This agreement is subject to and shall be interpreted and construed in terms of the laws of the Republic of South Africa and is subject to the jurisdiction of a competent court in the Republic of South Africa.

7. CONFIDENTIALITY:
Confidentiality will be maintained within the ethical boundaries discussed with the practitioner. Attendance of other parties, if desired, will be negotiated between the client and the practitioner in advance. The accounts department will only be provided with contact details, treatment and ICD-10 codes.

8. CONSULTATION:
The duration of an individual session is 51 – 60, 65 – 90 or 95 – 120 minutes. Appointments cancelled within less than 24 hours will still be invoiced.

9. COST STRUCTURE:
When claiming from a medical aid it will be at scheme rates. The fees below indicate the minimum cash fees payable.
51 – 60 minutes R 520
65 – 90 minutes R 800
95 – 120 minutes R 1200
Assessments and Reports R750

These rates apply to private patients or when a medical aid doesn't cover a session. Session charged through a medical aid are charged at scheme rates.