Patient Form – English

Dr Pierre Mouton Patient Form

PERSON RESPONSIBLE FOR ACCOUNT

PATIENT’S DETAILS

LIABILITY

I confirm that the information supplied is true. I agree that it is the responsibility of the member to obtain pre-authorisation for procedures. The member will carry all costs/penalties incurred as a result of failed pre-authorisations. I further understand that the member is personally responsible for settlement of the account and if applicable for submission thereof to the medical aid. Should legal steps be instituted for collection of this, I shall be liable for the costs on an attorney/client scale.
I hereby give consent that the ICD 10 codes of my examination(s) may be disclosed to my medical aid and referring doctors.


PLEASE NOTE: This practice charges Private rates.

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