AGREEMENT ENTERED INTO BETWEEN DR RIAAN OLIVIER AND PERSON RESPONSIBLE FOR ACCOUNT / PATIENT

Are you the person responsible for the account or the patient? (select both if applicable)

Responsible Person (hereinafter referred to as “the responsible person”)Patient (hereinafter referred to as “the patient”)

and

Dr Riaan Olivier
(hereinafter referred to as “the doctor”)

The responsible person / patient hereby agrees as follows:

1. That (s)he is liable to pay for clinical services rendered by the doctor to the patient and, to the extent that it is applicable, (s)he is the parent / legal guardian of the patient;

2. To pay within 30 days the account of the doctor in accordance with the tariff of charges prevailing in the doctor’s practice.

3. To settle the doctor’s account timeously and in full, as agreed, irrespective of contracts / agreements / arrangements (s)he may have with any medical scheme or any third party;

4. Should the doctor institute legal action against the responsible person / patient for recovery of any outstanding debts, to pay all legal costs, including attorney and own client costs, collection fees and tracing fees;

5. It is acknowledged that, in accordance with the provisions of Section 53(1) of the Health Professions Act of 1974 (duly amended) and Section 6(c) of the National Health Act 61 of 2003, the costs associated with all clinical services rendered by the doctor, treatment and / or procedures have been discussed and were fully explained to the responsible person and / or patient, to the extent required in law and professional ethics;

6. All information is regarded and treated as strictly confidential by the doctor and the practice staff. You hereby consent in terms of the Protection of Personal Information Act 4 of 2013 (“POPIA”) as amended from time to time, that the doctor / practice staff may disclose personal information about the responsible person and / or the patient, including identifying detail, diagnoses or diagnostic codes, to relevant third parties (such as funders, administrators, switching companies, and the like) for purposes of processing payment of accounts and in respect of clinical services rendered to the responsible person / patient. Failure to submit the correct codes might lead to the claim being incorrectly paid or rejected by your medical scheme of funder. Your personal information will be securely retained by the doctor / practice after your last visit to the practice, for as long as is required by legislation. You further hereby consent that the doctor / practice staff may contact you by any one of the following communication methods/platforms/systems (“communications”); namely: phone, SMS, Email, social media platforms such as WhatsApp, Telegram, Signal, Zoom or similar services or any future communications. You understand that these communications will be used for professional communication only. This will include (but not be limited to) accounts, statements and information, practice information, system updates, professional updates, consultations, and reports where necessary and indicated. You acknowledge that none of these communications are completely secure or encrypted communications, and you will not hold the doctor / practice staff responsible for any breach of confidentiality via these communications.

7. In the event of other third-party request for confidential information from the doctor / practice, such information pertaining to your background, clinical information, test results / diagnoses and treatment will only be furnished with your prior written informed consent.

I have read and agree with the above terms and conditions.

All Patients / Responsible persons:

I hereby further consent to:

• the responsible person’s / patient’s clinical information being shared with all healthcare professionals (e.g. GP, psychiatrist, other specialists, allied healthcare workers) involved with the responsible person’s / patient’s care;

• the doctor requesting clinical information from any professional currently or previously involved in responsible person’s / patient’s care.

I have read and agree with the above terms and conditions.

If the responsible person / patient does not inform the practice of cancellation of an appointment with at least a 24-hour notice period, the responsible person / patient will remain responsible for settling the full account for the consultation.

I hereby acknowledge that I am aware that telephonic / virtual consultations will be charged according to standard rates. I acknowledge and agree to pay for the compilation of reports / letters which may be requested by myself or third parties (including referring doctors), which will be charged according to standard hourly rates.

Like any other treatment I hereby acknowledge that the treatment may also have some unintended side effects, which will be discussed during consultation. I agree with the treatment interventions decided between the doctor and myself.

I hereby acknowledge that I have read and understood the above information. I have also been given the opportunity to ask questions prior to having signed this contract and acknowledge that all information submitted by me is true and correct. I understand that I am under continued obligation to advise the doctor / practice of any changes of my information, or consent, or medical condition, that may occur after submission of this contract and acknowledge, by signing this contract, that I am legally bound by the provisions of the contract.

I have read and agree with the above terms and conditions.

Emergencies: 082 3700600
E-mail: info@neuropsychology-practice.com
• Please ensure that you have signed the agreement document.
• Please have your ID and medical aid membership card photocopied at reception.

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