popi-ls - Dry Optometrist

Dry Optometrist Pty (Ltd)- PATIENT REGISTRATION FORM

Dear Valued Patient, This document explains the general conditions under which this practice sees patients and serves as a binding contract between you, the patient, and Dry Optometrist Pty (Ltd).

1. Person responsible for the account.

First Name

Initials

Phone Number : Personal *

Residential Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Phone Number : Work

2. Medical Aid Details

Only supply if applicable

Medical Aid Name

Medical Aid Plan

Medical Aid Number

Main Member

Dependent Code

3. Emergency Contact Details / Next of Kin

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Name and Surname

Phone Number : Personal

Phone Number : Work

4. PAYMENT AGREEMENT I understand that this contract is entered into between Dry Optometrist Pty (Ltd) and me, and not any other third party. I understand that payment for services rendered by Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd) without the receipt of a quotation and without my expressed informed consent. *

5. MEDICAL AID MEMBERS It is important to note that the relationship is always between Dry Optometrist Pty (Ltd) 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. Dry Optometrist Pty (Ltd), 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.

6. PROTECTION OF PRIVATE INFORMATION

Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd). I also acknowledge that the capture and storage of my personal information by Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd) 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.

9. FOR PERSONS ACCOMPANYING A MINOR BUT NOT THE NATURAL PARENT OR LEGAL GUARDIAN I hereby confirm that I am a major and am duly authorised to accompany the minor patient by the minor’s parent or legal guardian. I further confirm that the Natural parent or legal guardian has acknowledged their liabilities relating to all costs incurred for any services rendered by Dry Optometrist Pty (Ltd).

7. ICD- 10 CODES

In accordance with the ICD-10 legislation introduced by the Department of Health and as stated in the Medical Schemes Act, Dry Optometrist Pty (Ltd) 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 Dry Optometrist Pty (Ltd) will be providing my personal details to my medical scheme when claiming for services rendered.

8. LIABILITY

8.1. Should I insist that services be rendered or materials be provided by Dry Optometrist Pty (Ltd) which is contrary to the advice or recommendations received from Dry Optometrist Pty (Ltd), 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.

8.2. Dry Optometrist Pty (Ltd) will assume responsibility for the after care of each patient for a period of two 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.

Signed At

Date *

10. FURTHERMORE I HEREBY DECLARE THAT ALL THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE. *

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