PATIENT INFORMATION FORM


Please complete so we have your details prior to your appointment with us

  • MAIN MEMBER
  • PATIENT DATA
  • CONSULTATION FEES
  • TERMS OF SERVICES

Main Member

ID No:

Surname

Full Names

Nick Name

Initials

Gender

Date of Birth

Title

Cell No.

Home No.

Work No.

Postal Address

Postal Code

Physical Address

Postal Code

Employer

Medical Plan

Medical Scheme

Medical Scheme

Plan/Option

Medical Scheme Number

Do you have Gap Cover?

Email Address

Email Statements

* If the patient is not the main member and the main member’s scheme declines to fund the care in full or at all, the adult patient is legally liable for the full costs of the care received.

Patient Data

Same details as main member?

ID No:

ID No:

Surname

Full Names

Nick Name

Initials

Gender

Date of Birth

Title

Cell No.

Home No.

Work No.

Fax No.

Email Address

Chronic Disease Medication

Dependant Code

Referring Doctor/Provider

If a child has been accompanied to the consultation by a parent who is not the main member, please complete:

Employer

Contact No.

Next of Kin

Surname

Full Names

Initials

Title

Email Address

Contact No.

Relationship

** Person with whom we are authorised to speak to about your healthcare / outcome of your procedure.

CONSULTATION FEES

BILLING POLICY AND TERMS AND CONDITIONS CONSULTATION FEES ARE PAYABLE ON COMPLETION OF THE CONSULTATION. It remains the responsibility of the patient to settle outstanding amounts that are not covered by the medical aid for consultations, consumables and procedures. ACCEPTED METHODS OF PAYMENT: CASH, EFT, CREDIT / DEBIT CARD (CHEQUES NOT ACCEPTED) (All account Queries: Contact Salome: +27 21 762 7295 +27 74 168 5437 / salome@capehandsurgery.co.za ) First Consultation R 910 (vat inclusive) Follow-up Consultation R 610 (vat inclusive) Unscheduled / Emergency Consultation (Applicable to in and out of hospital) R 1060 (vat inclusive) We are contracted in to Fedhealth. In-Hospital Cost for Surgery Procedures For Dr van der Spuy’s account only. There will be separate invoices from the hospital, anaesthetist, pathology, radiology etc. • Discovery Classic Rates 217% Discovery Rates • Other Medical Aids 250% MASA Rates • International Rates 300% MASA Rates • We are contracted in to Fedhealth and all Discovery Classic Plans only. • BMI (Body Mass Index) greater than 35 will be additionally charged for as it increases the risk of the procedure. • It is the responsibility of the patient to contact their medical aid to obtain authorization. Post Surgery (up to 4 weeks) Rehabilitation ConsultationsIf management by a Hand Therapist is required, the patient be billed will be billed separately by the Hand Therapist. No charge for consultation but wound care items will be billed Compiling and Drafting of Medical Reports R1000 / 30 min (vat inclusive) Completion of PMA /Insurance Forms R 560 (vat inclusive) Repeat scripts R 160 (vat inclusive)

Terms and Conditions

TERMS OF SERVICES

I, the undersigned do hereby: Understand that the practice may charge fees in excess of my medical scheme’s rates, dependent on plan, benefits structure and current accepted medical scheme networks as stipulated in the above billing policy. Accept that I am fully responsible for payment of services rendered, and that, should I not pay timeously, additional debt recovery and / or legal costs will be generated for which I will be liable. Understand that diagnostic and procedural information (as well as any related photographs) related to my treatment may be utilised for practice statistical, research and / or teaching purposes. All such information will be dissociated from patient information and informed consent will be obtained by the practice if any of my information is required for clinical trials or research. I have the right to decline the taking of photography or the use of any images by the practice. Health and privacy legislation requires that we contractually agree to keep your information confidential. In this document we confirm this undertaking. Certain laws may however compel us to disclose your personal and health.information, such as laws that govern motor vehicle accidents, injuries and diseases that occur at your work, or claims to medical schemes. If you do not want us to release information to these entities, please let us know before you leave the practice. In those cases those entities will then not cover the costs of your care, or pay out other claims. You will then have to pay us directly for the services we have rendered. In all other cases we will require your written consent before releasing information to family members, your employer, insurance companies, etc. Kindly note that if your initial consultation or procedure was captured as private/medical aid on our system, we cannot change the claim to injury on duty after this. All amounts due will be the responsibility of the patient/main member of the medical aid. In this instance, the patient will then have to communicate with the Compensation Fund directly.

Terms of Services

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