PAYMENT AGREEMENT
I understand that this contract is entered into between Van Neel Optometrist and me, and not any other third party. I understand that payment for services rendered by Van Neel Optometrist remains my responsibility and I therefore agree to pay for all services rendered under this agreement.
I understand that no services will be rendered or products dispensed by Van Neel Optometrist without the receipt of a quotation and without my expressed informed consent.
MEDICAL AID MEMBERS
It is important to note that the relationship is always between Van Neel Optometrist and me, the patient, and the role of the medical aid is simply to act in the capacity of a third party payer on my behalf. I understand that, in the event of insufficient funds at medical aid level, for whatever reason, the onus is on me to pay any outstanding amounts.
Van Neel Optometrist, of course , as a service to me, as a valued patient, will liaise with my medical aid, to the best of its ability, to ensure availability of funds, payment follow up etc.
I understand that there are no guaranteed payments from medical aids at this time despite the fact that benefits may have been confirmed by the medical aid prior to services rendered and/or the submission of a claim as the status of accounts can change prior to claims received by the medical aid.
PROTECTION OF PRIVATE INFORMATION
Van Neel Optometrist is obligated to protect personal information of patients, legally and ethically, at all times. I thus understand that no personal information will be disseminated to any third party without my expressed informed consent.
I acknowledge that once my personal information is passed on to a third party by Van Neel Optometrist with my consent, whether on the basis of a referral to another practitioner or for the purposes of a medical aid claim, the information thereafter falls outside the control of Van Neel Optometrist.
I also acknowledge that the capture and storage of my personal information by Van Neel Optometrist is necessary to ensure an updated and complete medical record related to my medical history in order for accurate diagnoses to be made with the appropriate treatment and/or corrective measures at any time, either by Van Neel Optometrist or another practitioner, where and if applicable. My contact details are only for the purposes of the practice record unless otherwise stated with my consent, as per Clause 4 above.
The patient record remains the property of Van Neel Optometrist and which is legally required to be retained by the practice for periods as stipulated by existing legislation. Patients are entitled to obtain details contained within such records, if so requested.
ICD- 10 CODES
In accordance with the ICD-10 legislation introduced by the Department of Health and as stated in the Medical Schemes Act, Van Neel Optometrist is obligated to disclose diagnoses to medical schemes with each claim in the form of a diagnosis code. In this regard I acknowledge and understand that Van Neel Optometrist will be providing my personal details to my medical scheme when claiming for services rendered.
LIABILITY
Should I insist that services be rendered or materials be provided by Van Neel Optometrist which is contrary to the advice or recommendations received from Van Neel Optometrist, I acknowledge that I shall not hold the practice, the practitioner or the practice owner liable for any consequences which may be deleterious or not to my liking. I also acknowledge that should further work be necessary to remedy such consequences, I will be fully liable for any related costs.
Van Neel Optometrist will assume responsibility for the after care of each patient for a period of three months which may involve minor adjustments to spectacles, sunglasses, etc, provided by the practice which is inclusive of the initial payment. However, I acknowledge that should any damage to my spectacles or frame be the result of gross negligence on my part, unauthorised work or malicious damage, that I will be responsible for any resultant additional charges for corrective work or replacement which may be necessary.