SUBMIT PATIENT INFORMATION

Patient Information


Person Responsible for Account


Medical Aid Information


Friend or relative not living in same house



ATTENTION:

It is the policy of this practise not to discuss the results of the examinations with patients. All enquiries in this regard should be directed to the referring doctor.

I accept that it is my responsibility to follow up with my doctor that he/she has received the reports of my examinations.

Notice Regarding Professional Fees


PLEASE FEEL FREE TO ASK FOR A QUOTATION FROM THE PERSONNEL FOR ANY EXAMINATION.
PRIVATE PATIENTS MUST SETTLE ACCOUNTS BEFORE LEAVING THE PRACTICE.
ON RECEIPT OF THE X-RAY, ALL PATIENTS MUST PAY THEIR CO-PAYMENTS.

• After 17h00 on weekdays and over weekends you will pay an additional call out fee for the radiologist over and above the examination.

• Owing to varying benefit designs and limits by the different medical schemes, it remains your responsibility to validate with your insurer which codes and tariffs are applicable, as well as to obtain pre-authorisation for CT-scans, Mammograms and Bone Density procedures. Please inform this practice if there are any prerequisites (e.g. formularies, preferred providers) which we have to adhere to according to your medical scheme.

• Even if this practice submits your account directly to your scheme, you will ultimately be liable for the full amount. In the event of non-payment, you will be liable for payment of all costs incurred to recover the amount, plus interest as specified by the National Credit Act.

• I agree that the information on the form of an ICD10 code (diagnostic code) regarding the outcome of the examination may appear on all relevant paperwork.

• I further agree that my x-ray report(s) may be e-mailed or faxed to the relevant referring doctor(s).

• I confirm that the information supplied on the reverse side of this form is true and agree that it is my responsibility to inform you of any change of details within 14 days.

Thank You