Informed Consent

Informed Consent:

Documentation for consent to financial responsibility of the account, release of information and to treatment are completed at the first visit. Patients will also receive these documents via e-mail.

The patient, guardian or main member of the medical aid must consent to being responsible to pay for physiotherapy services and accept the terms and conditions of the practice – even though you might have a medical aid, the responsible person remains liable until the account is settled in full. Remember, we do not have a contract with the medical aid, you the patient or main member has – we cannot contract on your behalf, dispute on your behalf, obtain authorisation or establish the benefit available for physiotherapy on your behalf.

Cancellation policy:

Patients must cancel an appointment at least TWO HOURS prior to the appointment time. This must be done in person at our offices or telephonically. Please: we do not monitor e-mails or SMS messages throughout the day and night, and therefore DO NOT ACCEPT SMS, electronic OR E-MAIL MESSAGES AS MEANS OF CANCELLATION.

In the event of an appointment not cancelled 2 hours prior to the appointment time; a late arrival or an appointment not kept, the patient (not the medical aid or compensation commissioner) will be held liable for payment of that appointment @ R300.00 per appointment.

Following are samples of the applicable documentation:

A: TOESTEMMING TOT FINANSIëLE AANSPREEKLIKHEID VAN FISIOTERAPIE  REKENING / CONSENT TO FINANCIAL RESPONSIBILITY OF PHYSIOTHERAPY ACCOUNT.

Ek die ondergetekende, verklaar hiermee dat ek  / I the undersigned, hereby declare that I:

  • Aanvaar volle finansiële verantwoordelikheid vir my fisioterapie rekening by Jacoline Scott Fisioterapeute Ing. totdat dit ten volle vereffen is, selfs al het ek ‘n mediese fonds. (Ons raai u aan om u mediese fonds te kontak en te bevestig of enige voordele vir fisioterapie behandeling beskikbaar is sowel as die bedrag wat beskikbaar is.) / Accept full financial responsibility for my physiotherapy account at Jacoline Scott Physiotherapists Inc. until it is settled in full, even if I have a medical aid. (We advise you to contact your medical aid and confirm whether you have any benefits for physiotherapy treatment as well as the amount available).
  • Ek verklaar hiermee dat alle persoonlike en finansiële inligting wat ek verskaf, waar en korrek is en dat ek Jacoline Scott Fisioterapeute Ing. binne twee weke sal verwittig, sou enige van my inligting verander. / I hereby declare all personal and financial information given as true and correct and that I will inform Jacoline Scott Physiotherapists Inc. within two weeks, should any of my information change.
  • Ek verstaan ​​die faktuur/heffings prosedures van Jacoline Scott Fisioterapeute Ing.en sal vra indien ek enige verdere inligting verlang rakende die rekening / I understand the billing procedures of Jacoline Scott Physiotherapists Inc. and will ask should I require any more information regarding the account:
    Fooie word gehef per modaliteit gebruik tydens elke behandeling en ‘n maksimum van vier behandelingskodes per toestand behandel sal gehef word tydens ‘n behandeling, met die uitsluiting van evalueringskodes en materiaal gebruik tydens behandeling. / Fees are charged per modality used during every treatment and a maximum of four treatment codes per condition treated will be charged, excluding evaluation codes and material used during treatment.
    • Behandelingskode-beskrywings word gebruik soos saamgestel deur die Suid-Afrikaanse Fisioterapie Vereniging (SASP). / Treatment code descriptors are used as compiled by the South African Society of Physiotherapy (SASP).
    • Mediese fonds tariewe sal gehef word, soos jaarliks deurgestuur aan Datamax ​​deur elke mediese fonds. / Medical aid fees are charged, as sent to Datamax annually by each different medical aid.
    • Eise sal namens u na u mediese fonds gestuur word, mits u mediese fonds elektroniese eise (EDI) aanvaar. Let wel: Indien u nie toestemming aan ons verleen om u inligting beskikbaar te stel aan u mediese fonds / versekeraar / befondser nie, sal hierdie reëling as nietig verklaar word. / Claims will be submitted on your behalf to your medical aid, should they accept electronic claims (EDI). However, not giving consent to release your information to your medical aid/insurer/funder will void this arrangement.
    • Die praktyk sal nie in enige dispuut tussen pasiënt en mediese fonds betrokke raak nie. / The practice will not enter into any disputes between patient and medical aid.
    • Ek aanvaar aanspreeklikheid vir die koste van behandeling indien ek as pasiënt of my afhanklike nie betyds vir behandeling opdaag nie, of afsprake nie betyds kanselleer nie (by praktyk kantore of telefonies en wel minstens twee ure voor die geskeduleerde afspraaktyd) – in hierdie geval sal ek aanspreeklik gehou word vir die betaling van die behandeling. / Patients not arriving in time for their treatment, or not cancelling appointments at said offices or telephonically at least two hours in advance (before appointment time scheduled) will be held liable for payment of that treatment.
    • Rekeninge kan betaal word via ‘n elektroniese oorplasing, per tjek of kontant. Kaart fasiliteite is nie beskikbaar nie. / Accounts may be paid via an electronic fund transfer, cheque or cash. Card facilities are not available.
    • Regsaksie kan geneem word indien rekeninge nie vereffen word binne ‘n redelike tydperk (ongeveer drie maande) nie. Indien regstappe geneem word as gevolg van die versuim om enige uitstaande bedrae betyds te betaal, sal die pasiënt of verantwoordelike persoon aanspreeklik wees vir die betaling van alle verwante regskoste op die skaal soos tussen prokureur en kliënt, insluitende invorderingskommissie en rente. / Legal action can be taken should accounts not be settled within a reasonable period (approximately three months). In the event of legal action being instituted as a result of failure to pay any outstanding amounts timeously, the patient or responsible person will be liable for payment of all related legal fees on the scale as between attorney and client, including collection commission and interest.
  • Ek verstaan ​​die voorwaardes en implikasies van die bogenoemde prosedures./ I do understand the conditions and implications of the above.

Ek verklaar dat hierdie toestemming nie onder dwang gemaak is nie. / I declare that this consent was not made under duress.

 

 

__________________________________                                                 ______________________
Handtekening: Persoon verantwoordelik vir rekening/                           Datum /

Signed:   Person accountable for account                                      Date

 

B. INGELIGTE TOESTEMMING TOT  FISIOTERAPIEBEHANDELING BY JACOLINE SCOTT FISIOTERAPEUTE ING./ INFORMED CONSENT TO PHYSIOTHERAPY TREATMENT AT JACOLINE SCOTT PHYSIOTHERAPISTS INC.

Ek die ondergetekende, verstaan ​​en verklaar dat / I the undersigned, understand and declare that:

  • Ek tydens die behandeling en evaluering moontlik spesifieke liggaamsdele moet ontbloot en ek verstaan ​​dat ek mag weier om dit te doen, indien en wanneer ek ongemaklik voel om dit te doen. / During the treatment and evaluation I might need to uncover specific body parts and I understand that I may refuse to do so if and when I do feel uncomfortable in doing so.
  • Die fisioterapeut sal nodig hê om my aan te raak ten einde effektiewe behandeling te verskaf en dat ek die fisioterapeut sal inlig indien en wanneer ek ongemaklik voel. Ek self, of die fisioterapeut, mag ook versoek dat ‘n chaperone behandeling bywoon. / The physiotherapist will need to touch me in order to provide effective treatment and that I will inform the physiotherapists if and when I feel uncomfortable in doing so. I myself, or the physiotherapist, may request a chaperone during treatment.
  • Dit is my reg om hierdie toestemming ter eniger tyd of vir ‘n spesifieke prosedure of modaliteit te onttrek. / It is my right to withdraw this consent at any time or for any specific procedure or modality.
  • Ek is in kennis gestel van die voordele en risiko’s van die toepaslike prosedures en modaliteite soos gekies deur die fisioterapeut vir my behandeling. Ek is in kennis gestel van alternatiewe prosedures en modaliteite. Ek is bewus van die feit dat my liggaam anders op behandeling mag reageer as ander pasiënte. / I have been informed of the benefits and risks of the appropriate procedures and or modalities selected by the physiotherapist for my treatment. I have been informed of alternative procedures and modalities. I am aware that my body might react different to treatment than others.
  • Ek verstaan ​​die prosedures en moontlike potensiële komplikasies van my behandeling en ek het die geleentheid gehad om my diagnose en behandeling te bespreek met die fisioterapeut sowel as om vrae te vra. / I understand the procedures and possible potential complications and I had the opportunity to discuss diagnosis and treatment with the physiotherapist and to ask questions.
  • Ek gee toestemming vir fisioterapie prosedures en modaliteite wat op myself/ my afhanklike uitgevoer word onderworpe aan die fisioterapeut se neem van toepaslike voorsorgmaatreëls. / I hereby consent to physiotherapy procedures and modalities that will be performed on me/ my dependent subjected to the physiotherapist taking relevant precautions. 
  • Die fisioterapeut kan my behandeling regime verander indien nodig: onderworpe aan die fisioterapeut se vooraf bespreking van die verandering in die behandeling met my. / The therapist may change my treatment regime if necessary: subjected to the physiotherapist discussing the change in treatment with me.
  • Ek sal die raad van die fisioterapeut volg en verstaan my verantwoordelikhede as ‘n pasiënt: Om behandeling en rehabilitasie prosedures te volg, om na my gesondheid om te sien, om die regte van ander pasiënte en gesondheidswerkers te respekteer, om die gesondheidsorg stelsel nie te misbruik nie en om akkurate mediese geskiedenis en inligting te verskaf aan die fisioterapeut. Indien ek hierdie verantwoordelikhede nie nakom nie of nie my kursus van behandeling voltooi nie, vrywaar ek die fisioterapeut van regsaanspreeklikheid rakende my behandeling. / I will follow the advice from the physiotherapist and understand my responsibilities as a patient: To follow treatment and rehabilitation procedures, to take care of my health, to respect the right of other patients and health providers, to utilize the health care system properly and not to abuse it and to provide accurate medical history and information to the physiotherapist. Should I refrain from these responsibilities or not complete my course of treatment, I release the physiotherapist from legal liability regarding my treatment.
  • Ek sal alle personeel by Jacoline Scott Fisioterapeute Ing. behandel met waardigheid en respek. / I will treat all personnel at Jacoline Scott Physiotherapists Inc. with dignity and respect.
  • Ek sal die praktyk kontak indien ek onseker voel oor my behandeling, diagnose, tuisoefeninge, tuisraad of rekening / I wil contact the practice in case of uncertainty regarding my treatment, diagnosis, home exercises and advice or account.

Alle inligting voorsien aan en gegenereer deur Jacoline Scott Fisioterapeute Ing. sal vertroulik hanteer word. / All information provided to and generated by Jacoline Scott Physiotherapists Inc. will be kept confidential. Ek gee hierdie toestemming vrylik en verklaar dat dit nie gedoen is onder dwang nie./ I give this consent freely and declare that it was not made under duress.

 ___________________________                                                __________________________
Handtekening : Pasiënt / Voog                                                  Datum

Signed:  Patient / Guardian                                                      Date

 

C. TOESTEMMING TOT DIE OPENBAARMAKING / VRYSTELLING VAN INLIGTING / CONSENT TO THE RELEASE OF INFORMATION

 Ek gee hiermee toestemming aan Jacoline Scott Fisioterapeute Ing. dat inligting rakende my diagnose (ICD 10 Kodering), mediese toestand, prognose, bywoning van behandeling en behandelingsprogram aan die volgende persone / instansies met die doel van vereffening of skikking van my rekening sowel as vir verwysing en verslagdoening bekend gemaak mag word: / I the undersigned, do hereby give consent to Jacoline Scott Physiotherapists Inc. to disclose information regarding my diagnosis (ICD 10 Coding), medical condition, prognosis, treatment compliance and treatment program to the following people / institutions for the purpose of reimbursement or settlement of my account, and for referral and reporting purposes:

Merk asseblief die entiteite waarvoor u toestemming gee: / Please tick the entities that you do give consent to:

Mediesefonds / Befondser / Medical Scheme /Funder:

Verwysende dokter / Referring Doctor:

Huisdokter / General Practitioner:

Werkgewer / Employer:

Skool / School:

Ander mediese personeel / Other medical professionals:

(indien verder verwys / if referred on)

Fisioterapie/Biokinetika kollegas/ 

Physiotherapy/Biokinetic Colleagues:

Ouers / Parents:

Eggenoot / Spouse:

Kinders / Children:

Versekeringsmaatskappy / Insurance Company:

Afrigter / Coach:

Ek verstaan ten volle dat hierdie ‘n wetlike vereiste is en dat ek die keuse het om nie toestemming te gee tot die openbaarmaking van my inligting aan enige party nie.  Ek bevestig dat ek hierdie verklaring sowel as my keuses vrywilliglik maak sonder beïnvloeding, dwang of verpligting deur enige party. Ek verstaan ook dat my inligting aan ‘n prokureur verskaf mag word, sou my rekening oorhandig word vir invordering. / I fully understand that this is a legal requirement and that I have a choice not to consent to such information being disclosed to any party.  I confirm that I have exercised my choice voluntarily and that this declaration and exercise of my choices was not made under duress. I also understand that my information may be supplied to an attorney, should my account be handed over for collection.

Ek vrywaar Jacoline Scott Fisioterapeute Ing. van enige aanspreeklikheid, skade of benadeling wat ek ookal mag lei as gevolg van hierdie openbaarmaking. Ek vrywaar Jacoline Scott Fisioterapeute Ing. ook van enige verdere onthullings. / I indemnify Jacoline Scott Physiotherapists Inc. from any liability, damages, prejudice or whatsoever that I may suffer as a result of this disclosure. I will hold Jacoline Scott Physiotherapists Inc. harmless of any further disclosures.

 

____________________________                               _________________________

Handtekening : Pasiënt / Voog                                     Datum

Signed: Patient / Guardian                                          Date