HartsMed Multi-discipline Medical Group Practice

Contact Details:

28 Hertzog Street

Hartswater, 8570

TEL: 053 474 0157/8

CELL: 083 262 7488

info@hartsmed.co.za

Patient Agreement to Practice Terms and Conditions

Please read this practice agreement carefully and only sign it if you have fully understood its contents, and agree to all of the terms and conditions contained in it. NOTE THAT THIS ENTIRE PRACTICE AGREEMENT CONTAINS PROVISIONS RELATING TO THE RISKS AND LIABILITY OF THE MEDICAL SERVICES PROVIDED.

I understand that I am entering into an agreement with the Practitioner either on my own behalf or on behalf of the patient. Reference to the Practitioner includes other practitioners in the Practice, practitioners covering for them, any locum, and their employees (all “the Practitioner”).

1. GENERAL
   1. I have freely and voluntarily (without undue influence) chosen to consult with or continue treatment by, the Practitioner, HARTSMED. Where I was referred to this Practice/Practitioner, I have agreed to such a referral.
   2. I will adhere to the policies and rules of the Practice.
   3. I will provide the Practitioner with up-to-date accurate information regarding my personal- and health information and relevant funding information.
   4. I understand that I have to disclose all relevant information, and if I do not do so, it could result in harm to myself or the person(s) I am responsible for. I understand that if I do not provide up-to-date accurate information, it could result in harm to myself or the patient or an unborn baby. I understand that I am responsible for the consequences of not providing correct and complete information.
   5. I will follow the instructions of, and co-operate with, the Practitioner regarding my healthcare.
   6. I will update the Practice and Practitioner of any changes to my personal, health and/or financial information.
   7. I will treat all persons in the Practice with dignity and respect.

2. CONTACTING THE PRACTICE AND INDIVIDUAL PRACTITIONERS
   1. I have indicated on the Practice’s personal information form what my preferred means of contact are, and I agree to be contacted in that way.
   2. I understand that I am responsible to ensure that my chosen means of communication is private, secure and frequently monitored.
   3. I understand that the Practitioner will not consult via SMS, WhatsApp or similar mobile messaging applications. I may direct non-urgent clinical queries and administrative matters to the Practice via email, which will be answered when reasonably possible. Clinical queries will be billed accordingly.

3. EMERGENCIES
   1. In the event of a suspected emergency, I will go to the nearest hospital’s emergency department.
   2. I understand that any delay or failure in this regard may result in serious harm to myself, the patient or an unborn baby.
   3. I am aware of and will consider the requirements of my medical scheme in relation to their Designated Service Providers (DSPs), even in emergencies.
   4. During the informed consent process, the Practitioner will inform me of the implications of healthcare treatment. I will also be informed of my responsibilities in relation to self-care. I undertake to contact the Practice without delay if any complication (whether expected or unexpected), side effects or adverse reaction arises. If I suspect that the incident is serious, I will go to the nearest hospital’s emergency department.
   5. I will at all times be alert to the chance of possible complications, side effects or adverse reactions arising from any treatment. As general guidance, the following steps should be considered where appropriate or reasonably indicated, in addition to any other advice or instructions I may have received:
      1. Pregnant patients: Call the emergency contact number and go straight to the labour ward at the hospital where the patient will be delivering, or the nearest emergency department if attending at that labour ward is not feasible.
      2. Non-pregnant patients: Call the emergency contact number. If for any reason the emergency contact cannot be reached, immediately take all reasonable steps to obtain medical advice and assistance, including but not limited to attending at the nearest emergency department.
      3. Post-operative patients: If you experience any of the following symptoms, you should, without delay, return to the hospital immediately and call the emergency contact number to inform us:
         1. your incision is red, swollen, or leaking a discharge;
         2. you develop a fever;
         3. you have severe nausea and vomiting;
         4. you have heavy bleeding, or vaginal bleeding that is a bright red colour;
         5. you have difficulty urinating, burning when urinating, or very frequent urination; and
         6. you experience worsening pain or any other worrying symptoms.
   6. I understand that the steps set out above are intended for general guidance, and that I must take all reasonable steps that the circumstances may require.

4. APPOINTMENTS, RESULTS AND FOLLOW-UPS
   1. I am responsible to keep my next booked appointment and there is no obligation on the Practitioner to remind me.
   2. All procedures will require post-operative follow-up appointments.
   3. I understand that appointments to provide me with the outcomes of test or screening results, to follow-up on my health and treatment, post-operative- and similar appointments are critical for my health and wellbeing.
   4. If I decline to receive test results, receive follow-up care or advice, etc., I release the Practitioner from legal liability for any harm that may result from my refusal or failure to honour the appointment.
   5. If I am unable to keep a scheduled appointment, I will cancel and reschedule as soon as possible, but not later than 24 hours before the scheduled appointment, unless an emergency prevents me from doing so.
   6. I will cancel appointments at least 24 hours before, and I accept that if I fail to do so, any missed appointments will be billed to me (and not to my medical scheme or insurer).

5. INSTRUCTIONS AND RELEASE FROM LEGAL LIABILITY
   1. I will follow all instructions provided by any Practitioner or Practice staff. If I am unable to do so, I will seek healthcare advice from the Practitioner before doing anything.
   2. In all cases where I do not follow, for whatever reason, the advice of the Practitioner or Practice staff, I release them from legal liability, as is authorised by the National Health Act.

6. PRACTITIONER AVAILABILITY
   1. I understand that the Practitioner is generally available during the Practice’s consulting times, which are Mon-Friday 08:30 – 16:30.
   2. Practitioners may be on call after hours to provide services in emergency departments or to hospitalised patients. I understand that my usual Practitioner may not be the practitioner seeing me in such circumstances.
   3. I understand that the Practice may use locums (a stand-in practitioner) when the Practitioner is not available, such as deliveries and emergencies.
   4. I am always free to visit another practice or practitioner, subject to the rules on changing and cancelling of appointments.
   5. For any administrative matters (e.g. patient details, payments, medical schemes, etc.) the Practice should be contacted during office hours.

7. INFORMED CONSENT
   1. I understand that the Practitioner is obliged to obtain informed consent before any health service is provided to me and this process normally comprises a discussion about:
      1. my health status, except where this would be contrary to my best interests;
      2. the range of diagnostic procedures and treatment options generally available;
      3. the material benefits, risks and consequences generally associated with each option, including prognosis (i.e. my prospects after the care was provided);
      4. the cost of the options; and
      5. my right to refuse health services, but I must be informed about the implications, risks, and obligations of such refusal. I have a duty to sign a discharge certificate or release of liability if I refuse to accept recommended health care.
   2. I understand that I should ask questions on any aspect that are unclear to me. If I do not do so, the Practitioner will assume that I have understood what was explained to me.
   3. If any change in my healthcare is necessary, the Practitioner will obtain consent for my chosen option.
   4. If I am unable to consent (e.g. I am unconscious), the Practitioner will obtain consent from the person I designated on the personal information form, or from my next of kin, or as the law allows.
   5. If I am unable to consent, and my life or limb is at risk, the Practitioner may proceed with such necessary healthcare, and will inform me afterwards. This will not apply if I have signed a “Do not Resuscitate” instruction.
   6. If there are specific treatment options or interventions that I, in advance, do not want undertaken, I will inform the Practitioner before treatment is rendered. I will release the Practitioner from liability should any negative consequence follow the choice(s) I have made.
   7. I understand that healthcare treatment is never without risk, such as side effects, adverse reactions and complications. I understand that these may occur without the Practitioner having been negligent. I understand that the risks may not always be predictable or avoidable.
   8. I also understand that the human body may react in different ways to treatment, even if the same healthcare is provided. A variety of factors, including other treatments, my own behaviour, and complementary or traditional care, could affect health outcomes.
   9. I understand and agree that by providing informed consent or refusing care, I have accepted the risks that have been explained to me.
   10. I understand that I have the right to seek a second opinion at any time.

8. CHAPERONES/AN ACCOMPANYING PERSON DURING A CONSULTATION/EXAMINATION
   1. If I or the Practitioner requires a chaperone to be present during any consultation, examination or treatment, guidance relating to the presence of a chaperone will be provided to me on request.

9. FEES
   1. The Practitioner’s current fees are available at the Practice reception. I agree to those fees.
   2. For procedures, I will be provided with a cost estimate, and if accepted, that will be binding. An illustrative list of fees for specific interventions is also attached to the fee list.
   3. I understand that my medical scheme may or may not cover all of the fees and it is my responsibility to check this with the medical scheme and submit motivations or anything else needed to get cover.
   4. I accept that I remain personally responsible for the full settlement of all fees charged by the Practitioner, irrespective of my medical scheme’s arrangements or pronouncements.
   5. I undertake to settle the account personally immediately after consultation/procedure or within 10 days after my medical scheme fails to settle the account at all or in full.
   6. I understand and accept that a 2% interest per month or any other maximum percentage that can be charged by law, on all overdue accounts and I will be liable for all legal and debt recovery costs incurred.
   7. I am aware that certain conditions are prescribed minimum benefit (PMB) conditions, and medical schemes have to fund the diagnoses, treatment and care costs in full, subject to certain rules set out in law. The Practice will ensure accurate coding of the healthcare service to identify care as pertaining to a PMB condition. I may however have to take matters up with the medical scheme if they do not fund a PMB in full.
   8. I understand that if I am a dependent on a medical scheme, the scheme may provide information submitted to it to the main member. The Practice will however not engage with the main member on the services provided to any dependent, unless the law so requires (e.g. in the case of children under the age of 12, or incapacitated patients).
   9. If I am a dependant on someone’s medical scheme, I still accept full financial responsibility for the settling of fees directly to the Practice if the scheme does not pay any or all fees.
   10. Accounts to medical schemes must, by law, contain an ICD code that identifies my diagnosis. I understand that this means that information relating to my diagnosis and care will be disclosed to the main member, by the scheme. If I do not want such disclosure, I will raise this with the Practitioner before receiving treatment and agree to pay for the treatment myself after the care has been rendered. The account will then not be sent to the medical scheme.
   11. I am aware that the Specialist Practitioner charges R200 above/at medical scheme rates.
   12. I understand that the fees of the Practitioner do not include any hospital, anaesthesiologist, or other third-party fees or costs (e.g. physiotherapy, pathology, blood services, etc.) unless specifically stated. I will contact the specific healthcare provider to obtain information on their fees and I will pay their fees independently.
   13. Fee increases will occur on 1st January and will be added to the fees listed. This is calculated on, amongst other things, medical scheme increases, the cost of running a practice, consumer price inflation, inflation on health services and goods, and so forth. Fee increases may, if circumstances demand, be increased during the course of a year, and will be communicated to all patients (new and existing).

10. PRE-AUTHORISATION OR MOTIVATIONS FOR TREATMENT
    1. Medical schemes may require pre-authorisation for a procedure (e.g. in hospital or in the rooms), or for treatments (e.g. certain medications, or medical devices, such as implants). It is my responsibility to ensure that the planned treatment is covered by my medical scheme. I acknowledge that it remains my responsibility to settle any fees or costs not covered by my medical scheme.
    2. I am aware that if a procedure is planned or requires hospitalisation, I am responsible to ensure that my medical scheme provides the required permission/authorisation and covers the financial costs of the procedure, hospitalisation, and related fees (or the portion of the cost that it covers) before I undergo the procedure. Once more, I acknowledge that it remains my responsibility to settle any fees or costs not covered by my medical scheme.
    3. Where a treatment is not generally funded in full by my medical scheme, such as treatment that falls outside of medical scheme formularies or treatment protocols, the Practice may assist you to motivate for the payment.
    4. Where my Practitioner has to do any of the above pre-authorisation- or treatment motivations, if I agree to the disclosure by the Practitioner of relevant personal and health information required for such a motivation, I accept responsibility for the cost thereof.

11. PRESCRIPTIONS
    1. The Medicines and Related Substances Act compels a pharmacist to substitute a prescribed medicine with its generic unless I refuse such a substitution, or unless the Practitioner writes “no substitution” next to each line item that should not be substituted.
    2. I will ask the Practitioner about my medicine options, and the generic substitution.
    3. Medical schemes may require that I only use medicines from their list. If such medicine is not appropriate for me, the Practitioner will inform me, and I may have to make payment or a co-payment, or have to motivate for an out of formulary medicine.

12. MEDICAL CERTIFICATES
    1. The Practitioner will only provide a medical certificate on request if my specific condition warrants such a certificate.
    2. The certificate will not contain a diagnosis, unless I provide written consent to the diagnosis being disclosed on the certificate.
    3. I understand that my employer, or any other entity, such as school or university, may require verification of the certificate, and/or investigate absences. The Practitioner will however not disclose any health information without my permission.

13. PRIVACY / PROTECTION OF PERSONAL INFORMATION ACT (POPIA)
    1. I understand that the Practitioner will comply with the POPIA and the National Health Act and will keep my medical information confidential, except where:
       1. I have consented to the disclosure in writing;
       2. the disclosure is necessary or incidental to the performance, the billing and the reporting of the services provided;
       3. a court has ordered the disclosure;
       4. the disclosure is required by law; or
       5. non-disclosure of the information represents a serious threat to public health.
    2. I specifically authorise and consent to the use and disclosure of my personal and medical information, as reasonably needed to:
       1. Facilitate my treatment by:
          1. any locum, Practitioner or employee within the Practice, or outside healthcare service provider, such as pathologists and radiologists to whom I may be referred;
          2. an affiliated practice or hospital staff member;
          3. any other practitioner for the purposes of obtaining a professional opinion regarding my condition or treatment that may be in my best interest;
       2. facilitate payment by my medical scheme or insurer, to the extent authorised by the law;
    3. I agree to audio/video recording of all consultations and interactions with the Practitioner. I accept that these recordings may be made and will form part of the Practice’s electronic patient records. I understand that I can revoke this consent at any time.
    4. I agree to the disclosure of my relevant information, where necessary, to any company or entity whose services the Practice engages to secure payment of overdue accounts, such as debt collection companies.
    5. Records will be kept as required by legislation and the Health Professions Council of South Africa rules for a period of seven years after my last visit to the Practice, and for children at least until they reach 21 years. I understand that certain records, e.g. occupational health records, may have to be kept indefinitely. In this Practice records will be archived after seven (7) years and then destroyed. If a specific law requires or permits a longer period, the Practice will store the records accordingly.
    6. I understand that the Practice will take appropriate and reasonable measures to store my personal and health information in a manner that prevents loss of, damage to or unauthorised destruction and/or unlawful access.

14. WITHDRAWAL OF CONSENT TO INFORMATION DISCLOSURE / USE
    1. I may withdraw any consent to disclosure and use of my information at any time in writing.
    2. I understand that I cannot withdraw consent for information that must be shared, by law, such as reporting requirements of notifiable conditions, or the inclusion of an ICD codes on a medical scheme claim, or my personal details on a certificate or invoice issued by the Practice.

15. COMPLAINTS AND DISPUTE RESOLUTION
    1. In case of a complaint or dispute arising regarding the conduct or services provided by either the Practitioner or Practice staff, I agree to inform the Practitioner of my concerns as soon as possible in order to allow joint exploration of appropriate resolution strategies, assisted by the Practice’s brokers/insurers, and where appropriate by the practice manager or other appointee of a medical professional association, to facilitate the process. The joint exploration of strategies may include a confidential and without prejudice pre-mediation meeting to inform all parties about mediating a dispute before any other legal action is taken.
    2. I understand that this Practice supports transparency and my right to autonomy at all times. This includes all adverse incidents/outcomes irrespective of whether or not they were unpredictable, unavoidable, due to negligence, or human error.
    3. If the complaint or dispute cannot be resolved informally, then in keeping with the spirit of the above, I commit to partake in a formal and independent mediation process prior to pursuing any arbitration or litigation.
    4. If the dispute is unresolved by mediation within 60 days of being declared or such further period as may be agreed, I agree that the dispute will be determined by arbitration under the rules of the Association of Arbitrators (Southern Africa) NPC (The Association) on application by any of the involved parties.
    5. The arbitrator appointed must be a retired judge, or practicing or retired legal practitioner appointed by agreement between the parties. If parties fail to agree on an arbitrator within 15 calendar days of any party requesting such agreement, either party may apply to the Association for the appointment of an arbitrator.
    6. The arbitration will be governed by the Standard Procedure Rules for the Conduct of Arbitrations of the Association current at the time of appointment of the arbitrator.
    7. Agreement with this dispute resolution process constitutes an agreement of indefinite duration, independent of this Practice Agreement. Any dispute, controversy or claim in contract or in delict between any party bound by this Practice Agreement, arising out of or in connection with the services provided by the Practitioner of Practice Staff during its currency or thereafter must, unless precluded by law, be determined in accordance with the process set out in paragraphs 15.1 to 15.6 above.

16. LIMITATION OF LIABILITY
    1. I agree I will not hold the Practitioner or the Practice responsible for any harm which result from a failure by myself or the Patient to comply with the terms and conditions in this agreement, or any law or instructions or guidance issued by the Practitioner or Practice.
    2. I agree that the Practitioner’s liability for claims by me or anyone else arising from one event or series of connected events, including costs and any unpaid fees, is limited to the amount of the indemnity provided by their professional indemnity insurers in respect of such claims.

17. DECLARATION
    1. I confirm that I have read and understood the contents of this agreement. I have had the opportunity to read this agreement and ask questions prior to signing it. I have had such questions answered to my satisfaction.
    2. I acknowledge that, by signing this agreement, I am, and any person I represent is, legally bound by the terms and conditions of this agreement in relation to the Practitioner, and where applicable, any employee of the Practice involved in providing services to me.

Both parties agree to accept an electronic signature of this form.