Patient Practice Contract Information

Patient

Patient Name (your first name):(Required)

Reference:

Physio

Specialist

Referring GP:

Tel:

Address:

Street Address

Referring Physio:

Tel:

Address:

Street Address

Referring Specialist

Tel:

Address:

Street Address

Main Member Information

ID Number:(Required)

Surname:(Required)

Full Names:(Required)

Initials:

Gender:

Male

Female

Title:

Date of Birth:(Required)

Home Language:

Employer:

Cell Number:(Required)

Home Number:

Work Number:

Fax Number:

Email Address:(Required)

Postal Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Same as postal address.

Physical Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Scheme:(Required)

Plan/Option:(Required)

Gap Cover:

Yes

Member No.:(Required)

Main Member Dep Code:(Required)

Are you (the Main Member) the Patient?(Required)

Yes

Practice Fee/Coding Guideline

DR. Matt Durrans Inc: Practice Fee/Coding Guideline

1st consult - 0191 Payable on the Day
Follow up visits - 0192 Claimed by Practice
Post op follow up visits - First four weeks - No Charge except if dressing change or procedure performed - Medical Aid Rates
"Push In or After Hours or Unscheduled Visits - 0146 or 0145 will be dded to consultation code 0191 or 0192 at Medical Aid Rates
Telephonic or email consultations - 0130 or 0132 - Medical Aid Rates
In room procedures - Medical Aid Rates
Disposables - Nappi Code Rates
Orthotics - Procedure to be discussed with Orthotist/Dr Durrans
Surgery - 3 x NHRPL Rates - Unless contract with Medical Aid
Medical Certificates or Scripts - 0132 - Medical Aid Rates
Third Party form completion and PMB Application forms completed - 0199 or 0133 or code stated by Third Party form will be added at Medical Aid Rates (may have to be paid before the form is released)
Email consultations or email requests from your Medical Aid for x-ray reports, responding to emails from your Medical Aid, Brocker or any Third Party will be charged accordingly - 0133 or 0130.
Medical report for Third Party - R4000 - To be paid before the form is releassed
Patient will be liable for surgical procedure codes NOT covered by Medical Aid
Most Gap Covers will cover shortfall. 15% will be added to all accounts if we do NOT have contract with Medical Aid.
I Hereby give Dr Durrans accounts department permission to query or motivate unpaid or shortpaid accounts by my Medical Aid or Gap Cover with the Medical Schemes Board/

General

You are responsible for the whole amount of the account irrespective of what the Medical Aid covers - Our contract is with you and NOT the Medical Aid.
Any payment made by your Medical Aid/Insurance must be paid over to the Practice Bank Account within 72 Hours. The OUTSTANDING amount is payable in full at your 4 week follow up visit.
The OUTSTANDING amount will be handed over to our Attorneys once it reaches 120 days OUTSTANDING (unless payment options have been discussed with our account managers, Flourish Bureau.)
Confirmation slips with your account NR as reference must be faxed to 021 982 2322 or emailed ro accounts@flourishsa.com otherwise it will remain unpaid on our system and penalties will be liable.
On OUTSTANDING accounts above 30 Days 2% Interest and a R50 Administration Fee will be added in Accordance to our Regulatory Bodie's Practice Conduct.
Social Media such as Whatsapp/TwitterFacebook and other webpages will NOT be answered - If any emergency/question please come into the Practice or the Emergency Department at Cape Gate.
Emails will be regarded as not Urgent and may NOT be answered.
Emails that are answered, may be regarded as a consultation and Billed Accordingly.

Name:(Required)

Signature(Required)

Date of Signature:(Required)