Terms and Conditions:
I hereby confirm that I personally take full responsibility for settlement of all accounts rendered by the service provider, regardless of whether or not I have Medical Scheme cover. I understand that this is a cash practice and that I first need to settle the account directly with the service provider, then claim back from my medical aid. I understand that the practice charges higher rates than what my medical aid would reimburse me.
I further confirm the following:
- My address, details of which are reflected on this form, is my chosen domicile (domicilium citandi et executandi) for all purposes relating hereto.
- The bank details completed on this form are my current, valid, and correct banking details.
- I consent to the Service Provider or any third party acting on behalf of the Service Provider debiting my bank account for all unpaid accounts in respect of services rendered by the Service Provider. In the event of the debit order being returned for any reason whatsoever and my account remaining unpaid for a period of 60 (sixty) days or more (calculated from the date of consultation with the Service Provider), I agree and hereby undertake to pay all legal costs (on a scale as between attorney and own client) incurred in the collection of the amount that is due to the Service Provider, as well as interest thereon at 15.5% per annum, calculated for the period from the date of consultation payment.
Bepalings en voorwaardes
Ek bevestig hiermee dat ek persoonlik volle verantwoordelikheid aanvaar vir die betaling van alle rekeninge wat deur die diensverskaffer gelewer word, ongeag of ek mediese skema-dekking het of nie. Ek verstaan dat dit 'n kontantpraktyk is en dat ek eers direk met die diensverskaffer die rekening moet vereffen, dan terug eise van my mediese skema. Ek verstaan dat die praktyk hoër tariewe hef as wat my mediese skema my sou vergoed.
Ek bevestig verder die volgende:
- My adres, soos op hierdie vorm aangedui, is my gekose domicilium citandi et executandi vir alle doeleindes wat hiermee verband hou.
- Die bankbesonderhede wat op hierdie vorm ingevul is, is my huidige, geldige en korrekte bankbesonderhede.
- Ek gee toestemming aan die diensverskaffer of enige derde party wat namens die diensverskaffer optree, om my bankrekening te debiteer vir alle onbetaalde rekeninge ten opsigte van dienste gelewer deur die diensverskaffer. In die geval dat die debietorder om enige rede teruggestuur word en my rekening onbetaald bly vir 'n tydperk van 60 (sestig) dae of langer (bereken vanaf die datum van konsultasie met die diensverskaffer), stem ek in en onderneem hiermee om alle regskoste te betaal (op 'n skaal soos tussen prokureur en kliënt) wat aangegaan mag word in die invordering van die bedrag wat aan die diensverskaffer verskuldig is, sowel as rente daarop teen 15.5% per jaar, bereken vanaf die datum van konsultasie tot en met betaling daarvan.
