Please have the person responsible for the account complete this form. 

 

This form serves as a contract between the person responsible for the account and Dr Katie Hamilton (hereinafter referred to as "the psychologist"). 

The person responsible for the account hereby agrees as follows: 

1.     That (s)he is liable to pay for services rendered by the psychologist 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 psychologist in accordance with the tariff of charges prevailing in the psychologist’s practice

3.     To settle the psychologist’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.     To pay simple interest on any outstanding amounts due to the psychologist for the medical services rendered at the rate of 24% per annum (i.e. 2% per month) from the date of rendering the abovementioned services until date of final payment, both days inclusive;

5.     Should the psychologist 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;

6.     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 medical services rendered by the psychologist, 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;

7.     In accordance with requirements, the psychologist is granted permission to disclose any information about the responsible person and / or the patient, including medical information and / or diagnoses or diagnostic codes, to relevant third parties (such as funders, administrators, switching companies, prescriptions to pharmacies, and the like) for purposes of processing payment of accounts and in respect of  medicines dispensed and / or medical services rendered to the responsible person / patient;

8.     In accordance with specific Acts or statutes, professional ethics or formal policies or directives applicable to the situation, that the doctor may release the ICD 10 codes to the funders and fellow medical professionals. The responsible person and / or patient have been informed that, in certain circumstances, such as disclosure of ICD 10 codes, the exact consequences of disclosing such information is unknown to the doctor and that information relating to these consequences must be obtained by the responsible person and / or patient from the third party to whom the information is disclosed.

 

By signing below, the person responsible for the account accepts the above terms:

 

The first appointment requires payment on the day, at the following rates:

• 50 minutes is charged at R1350.00
• 80 minutes is charged at R1800.00
• 2 hours is charged at R2100.00

Thereafter, neuropsychological services are charged at standard medical aid rates. These fees are specific for each medical aid provider and can be provided on request. Cash rates are based on the Discovery Health rates, and are as follows: 50 minutes is charged at R1245.00; 80 minutes is charged at R1800.00; 2 hours is charged at R2100.00. All telephonic consultations will be charged (except for first call to make the appointment), as will all reports.

 

If the responsible person does not inform the practice of cancellation of an appointment with at least a 24 hour notice period, the responsible person will remain responsible for settling the full account for the consultation, which will not be covered by medical aid.

 

By signing below, the person responsible for the account accepts the above terms: