THERAPEUTIC CONTRACT-HEARING FEES

These are approximate prices and the invoice amount will depend on the time taken and tests conducted on the day of your consultation. All hearing test prices already include the consultation fee. Hearing services are charged at an average of medical aid rates and therefore there may be a shortfall, depending on the specific rates that your specific medical aid has chosen.

This document explains the general conditions under which this practice sees patients and serves as a binding contract between you, the patient, and Calligaro & King Inc.

PAYMENT AGREEMENT

I understand that this contract is entered into between Calligaro & King Inc and me, and not any other third party. I understand that payment for services rendered by Calligaro & King Inc 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 Calligaro & King Inc without my expressed informed consent. I understand that Calligaro & King, Inc will not get involved in any medical aid legal disputes. Should full payment not be received within 60 days, the account will be handed over to our legal department. In the event that we are compelled to take legal action for the recovery of our fee, the principal member/patient will be responsible to pay all legal costs on attorney and patient scale, collection charges and tracing fees.

MEDICAL AID MEMBERS

Hearing service invoices will be submitted directly to your medical aid. However, it is important to note that the relationship is always between Calligaro & King Inc 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. Calligaro & King Inc, 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

Calligaro & King Inc 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 Calligaro & King Inc with my consent, whether on a basis of a referral to another practitioner or for the purposes of a medical aid claim, the information thereafter falls outside the control of Calligaro & King Inc. You can at any time, withdraw this consent and that your personal and medical information will thereafter not be processed other than for payment purposes for treatment/services rendered.
I also acknowledge that the capture and storage of my personal information by Calligaro & King Inc 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 Calligaro & King Inc or another practitioner, where and if applicable. My contact details are only for the purpose of the practice record unless otherwise stated with my consent to receiving extra correspondence. The patient record remains the property of Calligaro & King Inc 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, Calligaro & King Inc 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 Calligaro & King Inc will be providing my personal details to my medical scheme when claiming for services rendered. You are entitled to refuse to have the ICD-10 codes reflected on the statement, although consequently you will not be able to be reimbursed by your medical scheme.

LIABILITY

Should I insist that services be rendered or materials be provided by Calligaro & King Inc which is contrary to the advice or recommendations received from Calligaro & King Inc, I acknowledge that I shall not hold the practice, 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.

This practice is not held liable and takes no responsibility for any accidents and/or injuries that may be sustained by you or your child while on the premises.

We, the undersigned hereby confirm that we have explained the therapeutic contract to you (the patient), and the proposed treatment and have answered any questions you may have had.

Please provide email addresses where correspondence can be emailed.