Patient Details form (Life Carstenhof Hospital)

Patient details & Confidentiality Disclosure consent Form

LIFE CARSTENHOF HOSPITAL
Full Name*

TitleInitialsSurname
First NameLast Name
Patient ID Number
Medical Aid
Medical aid plan
Medical Aid number
Dependant code
Dependant Code
Person Responsible for account
Full Name*

TitleInitialsSurname
Full name
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ID Number
Date of Birth

MonthDayYear
Date
Employer
Home Tel:
Work Tel:
Cell:
Email:
Spouses Cell:
Spouses work Tel:
Next of Kin (not at the same address)
Full Name*

TitleInitialsSurname
Full name
Relationship
Tell:
Referring Dr Name:
CONFIDENTIALITY DISCLOSURE AND PAYMENT AGREEMENT

I, the undersigned, as patient, spouse or legal guardian, hereby authorise Dr. A Khan and his accounts department who is in possession of information concerning my medical diagnosis and treatment,
together with my health and personal particulars to disclose such information to my Healthcare Funder and other Healthcare Providers.
I further wish to indicate that such permission to disclose such information is only for the purpose of treatment and management of my medical condition.
CONFIDENTIALITY DISCLOSURE AND PAYMENT AGREEMENT
I, the undersigned, as patient, spouse or legal guardian, hereby authorise Dr. A Khan and his accounts department who is in possession of information concerning my medical diagnosis and treatment,
together with my health and personal particulars to disclose such information to my Healthcare Funder and other Healthcare Providers.
I further wish to indicate that such permission to disclose such information is only for the purpose of treatment and management of my medical condition.

I, the understanding, hereby agree to the following:
Agree to pay accounts received within 30 days should my medical aid default or should I be a private patient. I undertake to be liable for all legal costs as between attorney and client as well
as tracing, collection and administration fees received by the above patient. The practice reserves the right to charge for appointments not cancelled within 24hrs. I testify that all the information is
correct and understrand that this statement constitutes a binding agreement.

I, the understanding, hereby agree to the following:
Agree to pay accounts received within 30 days should my medical aid default or should I be a private patient. I undertake to be liable for all legal costs as between attorney and client as well
as tracing, collection and administration fees received by the above patient. The practice reserves the right to charge for appointments not cancelled within 24hrs. I testify that all the information is
correct and understrand that this statement constitutes a binding agreement.
Full Name
Date

MonthDayYear
Date
Signature

Admin use

	Service date	Patient	Comment	ICD 10	Procedure codes
1
2
3
3

Should be Empty:

Patient details & Confidentiality Disclosure consent Form

Person Responsible for account

Next of Kin (not at the same address)