- Agree that my personal information, if I am under the age of 18, may be disclosed to my parents, guardians or other persons authorised in terms of the law.
- Agree that the Service provider, (Sr Helen Cyster), can request from me that confidential medical information disclosed by me during my consultation, be disclosed to my referring doctor and/or to any other healthcare professional and/or to the medical aid, where the disclosure of such information would be to the benefit of my overall health.
- Agree to the disclosure of ICD-10 codes, which would reveal my diagnosis, to the medical aid scheme.
- Agree that accounts in respect of the services rendered by the Service provider, may be submitted to my/the member’s Medical Aid scheme for purposes of payment.
- Agree that the Service provider will be entitled to charge the applicable fees as provided by my/ the member’s Medical Aid Scheme.
- In the event that I am a Private patient, I agree that the Service Provider will be entitled to charge the fees as agreed to between the Service provider and myself, such fees to be agreed to before the commencement of the consultation.
- I understand that I am fully responsible for the payment of my account and not my/the member’s medical aid scheme. I understand that I am given 30 days from date of invoice in which to settle my account.
- I understand that if payment is not made within 90 days of date of the invoice, the account will be handed over to the Service provider’s attorney for collection and I will be liable to pay any collection and attorney’s fees on an Attorney/Client scale.
