NOTICE OF PRIVACY PRACTICES

Dear Valued Patient,

We understand that medical information about you and your health is personal. As the custodians of the information in your medical record, we are committed to protecting the privacy of your information as required by law, professional accreditation standards and our internal policies and procedures.

This notice explains your rights, our legal duties and our privacy practices. It also describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully. Your signature only acknowledges that we have presented for your review the Notice of Privacy Practices.

General Terms and Conditions Applicable to Persons Joining this Practice as Patients

This document explains the general conditions under which this practice sees patients. It does not constitute an informed consent to any specific treatment, nor a quotation or price for any service rendered by the practice. Informed consent and price information will be provided each time you visit the practice, and will depend on the care you need/seek, and other factors such as your medical scheme cover.

This serves as a binding contract between you, the patient, and the above practitioner. You may only sign on behalf of yourself or your dependents under the age of 18 years or authorised dependents. For patients on medical aid scheme plans and over the age of 18 years and registered as dependents on a medical aid scheme plan, an individual signature is required on a separate form as a binding contract with this practice.

You are obliged to provide your informed consent for any medical investigation, treatment or procedure to be performed by the doctor. Your rights obligate the practice to discuss the clinical aspects, financial implications pertaining to your health status, the diagnostic process as well as the different treatment options available. You have the right to retract your informed consent at any stage or to refuse such medical care. Should your treatment include admission to a healthcare facility where other healthcare specialists (like anesthesiologists, physiotherapists, etc.) also become involved in your care and management, you are required to provide informed consent to their respective treatment and professional fee policies.

Under the provisions of The Children's Act, children may consent to certain medical treatment from the age of 12 years. Parents / guardians are however required by law to cover the expenses incurred for the healthcare of their children. Doctors are obliged to guard the healthcare information of these children and to keep it confidential and only divulge the information subject to the child’s consent. Please request the practice management staff to provide examples of these conditions, should you require further information.

What does your medical aid cover?

In the current medical aid market environment, patients are purchasing lover cost medical aid plans with restrictive limits on treatment with less benefits, medicine restrictions, limited hospitalisation and surgery cover, public hospitals as providers or pre-determined treatment and surgical procedures, and restrictions on access to doctors.

Your treatment and financial costs of your professional care can be severely affected by the type of medical plan you belong to and the generalisation of statements such as “100% cover” by your medical aid or may not correspond with all the aspects of treatment you may require. These limitations often prove problematic for your doctor as the right to obtain the necessary professional medical care that meets an acceptable standard is being influenced by your choice of medical aid cover.

It remains your primary responsibility to familiarise yourself with the benefits and conditions of your medical aid plan. It is important that you know your benefit status with regard to the extent of your health cover, referral restrictions, savings account balances registration and pre-authorised processes, waiting periods and other requirements. The Medical Schemes Act 131 of 1998 and its regulations entitle members of a medical scheme to all information on their benefits and limitations of their plan. You are responsible to acquaint yourself with the benefits, insured rates and terms and conditions of your medical scheme plan. Drs Siddi Ganie Inc. does not assume responsibility for verification of medical aid benefits or explanation of patient’s coverage, co-payments, deductibles or pre-existing conditions. Verification of medical aid coverage is not a guarantee of payment for all medical services recommended or performed by Drs Siddi Ganie Inc. The patient’s medical aid coverage is a contract between the patient and their medical aid. It is the patient’s responsibility to understand their medical aid coverage, all policy limitations and preferred providers under their policy. The patient is responsible for all denied or non-payment of charges from your medical aid company or medical group. The final determination of your eligibility and benefits is done by your medical aid company or medical group.

Ascertain the exact amounts your scheme provides for in terms of consultations, procedures, assistants as well as what your medical aid will pay and not pay for.

Where a Designated Service Provider has been appointed by your medical aid, it remains your responsibility to be cognizant of this and to bear responsibility for any restrictions that may follow (either medically or financially) when consulting a non-designated doctor or facility

With ever increasing intervention from your medical scheme, please be aware that this practice with not allow a medical aid scheme to violate the doctor’s professional and clinical independence.

Where a medical aid or its advisors intervene to overrule your doctors preferred diagnostic approach or treatment, your doctor assumes no responsibility for consequent adverse outcomes. You may be asked to assume responsibility to the medical advisors in the event of complications.

Billing Procedures

Please be aware that when you use a medical aid plan or designated medical group for reimbursement of medical services, that third party makes the final determination with respect to approval and reimbursement of all of the medical care rendered to you.

The staff and physician as Drs Siddi Ganie Inc. would like to be a “partner” with patients in providing medical care and with the complex process of healthcare reimbursement in today’s often extremely confusing and financially difficult environment. In order to best serve patients and at least try to clear some of the confusion with respect to billing your medical aid or third party payer, please be aware and adhere to the following office policies:

The policy of this practice is to charge cash for consultations, payable at the time of consultation.

A current valid medical aid card can be produced if possible and we must obtain a copy to provide proof of medical aid cover.

Valid picture identification (we must obtain a copy for the patient file).

If you are not ready to pay your cash at time of checking in for your appointment, you will be rescheduled.

Failure to collect monies owed from patients by our office is considered fraudulent as per contract terms.

Drs Siddi Ganie Inc. does not assume responsibility for verification of medical aid benefits or explanation of patient’s coverage, co-payments, deductibles or pre-existing conditions. Verification of medical aid coverage is not a guarantee of payment for all medical services recommended or performed by Drs Siddi Ganie Inc.

The patient’s medical aid coverage is a contract between the patient and their medical aid. It is the patient’s responsibility to understand their medical aid coverage, all policy limitations and preferred providers under their policy.

The patient is responsible for all denied or non-payment of charges from your medical aid.

The final determination of your eligibility and benefits is done by your medical aid company.

Settling of Accounts:

To avoid misunderstandings regarding payment policies and to maintain the professional healthcare standards of this practice, you will be informed of the current payment options and policies available in the practice.

These fees are determined based upon the appropriateness of the quality and standard of services rendered. No accounts will be rendered for services not delivered or delivered to someone else. The practice personnel can inform you if the practice has an agreed policy in place with your medical scheme, at your request.

This practice reserves the right to claim directly from you in which case you will be provided with an invoice that is payable to the practice within 30 days from the date of service. You have the prerogative to claim this back from your medical aid this practice submits accounts subject to the National Credit Act, The Consumer Protection Act, the Medical Schemes Act and the guidelines as published by the HPCSA.

This practice reserves the right to charge a service fee for any credit given in terms of the provisions of the National Credit Act, Act No. 34 of 2005. In terms of section 101(1)(c), an initial per transaction service fee may be charged on the transactions for which a credit amount is provided and thereafter on a monthly basis for each month a credit balance remains. In terms of section 101(1)(d), interests may be charged on the amount for each month the credit amount is not paid by you. Where legal action is instigated for the recuperation of costs for services rendered or goods provided in terms and associated with the rendered services by this practice then, in terms of section 101(1)(g), collection costs may be imposed to the extent permitted by Part C of Chapter 6 of the National Credit Act, Act No. 34 of 2005.

You will be informed of the practice billing policy and the prices for services generally rendered by the practice. Where an exact price cannot be presented, a quotation aligned with these applicable laws will be provided, subject to its own terms and conditions. This will be discussed with you at every visit or treatment event to the practice.

You (or your parent/guardian) remain at all times liable for the account for services rendered by this practice even if you are insured by a medical aid or other third party. Accounts not paid by the medical aid for services remain the patient's responsibility to settle. This agreement does not preclude the practice from taking all reasonable and practical steps to recover any outstanding amounts.

It remains your responsibility to inform and update all personal and medical aid detail information with the practice and that you undertake to keep the practice regularly informed with regards to any changes on your contact details, benefits and list of dependents. Please note that the use of someone else’s medical aid card with or without such a person’s consent or knowledge constitutes fraud. This practice will report such instances to the medical aid concerned to protect the practice from being regarded as a cooperative in the fraud.

Any disputes regarding the approval of payment by the medical aid company are between the patient and their medical aid company or medical group. Your medical aid may deny payment if your medical aid company or medical group (not your doctor or Drs Siddi Ganie Inc.) determines that:

The care provided is not medically necessary.

The care provided is a non-covered benefit.

The patient is ineligible to receive benefits under the plan.

The policy is terminated.

Services were provided by a non-participating or out of network provider.

A referral and/or pre-authorisation are necessary.

Pre-existing conditions applies.

Additional information from the patient is necessary.

Incorrect billing and demographic information was obtained from patient.

By signing this agreement, you give consent and acknowledge understanding that all services you consented to and provided by Drs Siddi Ganie Inc may not be covered by your medical aid company for any one or all of the reasons listed above; and that you give your consent for Drs Siddi Ganie Inc. to collect from you any charges for services that were rendered to you (but not covered by your medical aid).

Pre-authorising

In the event that hospitalisation is required, it remains your responsibility to ensure that the planned treatment is covered by your medical aid and that the necessary finances are put in place to cover the non-insured costs. If pre-authorisation is required for any intervention, it also remains your responsibility to furnish the practice with the relevant information and authorisation numbers.

If your medical aid plan requires an authorisation from your general practitioner(GP) for a particular service, you will need to contact your GP for the authorisation. Receiving an authorisation is the patient’s responsibility and NOT the specialty office. Services that have already been rendered to patients without first obtaining the required authorisation are deemed as part of the patient’s consent for the non-authorised service and will be payable upon receipt of invoice from our office.

Where your medical aid questions the appropriateness of your treatment, your doctor may submit a letter of motivation to the medical scheme if appropriate and may also insist on a peer-to-peer discussion in the above instances.

Non-Contracted Medical Aids

If you have medical aid with a plan with which Drs Siddi Ganie Inc. does not have a contract, the charges for your care and treatment are due at the time of service at non-contracted rates.

Self-pay accounts

Self-pay accounts are patients without medical aid coverage, patients covered by medical aid plans in which the office is not contracted to, liens, personal injury cases, auto accident insurance, RAF cases and worker’s compensation cases.

Third Party Cases

(Liens, Personal injury, Workman's compensation, RAF)

Drs Siddi Ganie Inc. does accept liens, personal injury cases, auto accident insurance, third party payments, and worker’s compensation cases on an individual case-by-case basis only. It is mandatory for patients to disclose if they are attending a consultation for purposes of third party claims. It is the patient’s responsibility to provide all third party contact information, in order for Drs Siddi Ganie Inc. to send itemised statements directly to them.

Outside Diagnostic Testing

(MRI, blood test, etc.)

If you are ever referred for any outside (i.e. not financially affiliated with Drs Siddi Ganie Inc.) diagnostic testing, you will receive separate billing charges from the companies performing the services. Please understand that Drs Siddi Ganie Inc. is in no way responsible for the charges related to the testing or medical care outside of Drs Siddi Ganie Inc.

Request for Medical Records

Copies of your records must be requested in writing. Copying fee applies and must be paid prior to mailing or collection of records.

R500 for 1-50 pages.

R1000 for 50-200 pages.

R1500 for over 200 pages.

Confidentiality

All information handled by this practice is regarded and treated as strictly confidential by the doctor and the practice staff. Should you belong to a medical aid and the medical aid forwards such an account to the principal member of the medical aid, confidentiality may be compromised as legislation compels this practice to provide certain information to the medical aid on the accounts. Failure to submit the correct codes might lead to claim incorrect being paid or not paid at all. Regulation 5(f) of the Medical Schemes Act (published in the Government Gazette No 20556 on October 20th,1999) states that an account to a medical aid must contain the relevant diagnosis. This must be submitted as an ICD-10 diagnostic code. It has become necessary to disclose these ICD-10 codes on prescriptions, referral letters, requests for special investigations (radiology,pathology, etc). If you choose not to allow us to reveal your ICD 10 coding, and your Medical Aid withholds funding as a result of this decision, you will then be required to settle the account.

In the event that a practice or its administrator approaches this practice with a request for confidential information and uncertainty exists over the soundness of the required confidentiality processes that has to be in place,the doctor will continue to follow the standard operating procedures as legislated in the Access to Information Act and its equivalent Acts or rules.

Your de-identified information may be used for epidemiological, research or practice business planning and may be passed on in a de-identified format to 3rd parties for further processing. For accurate health care planning, it is important that as much as the required information is included in these types of analyses and that your participation in this regard is highly appreciated.

I understand the implication and agree to, where appropriate, the doctor and practice disclosing my ICD-10 diagnosis code(s) under the conditions described above.

I agree with the release of the appropriate medical information by Drs Siddi Ganie Inc. for motivations and / or requests for authorisation.

Online Communication and Social Media

The staff at Drs Siddi Ganie Inc. are aware of the positive benefits of social media such as Facebook, YouTube, Twitter, etc. However, please be aware that your private health information is protected by laws which prohibit sharing or discussing specific health-related information on any social media site. In efforts to protect your privacy, we ask that you refrain from discussing or asking any specific health-related information on social media sites.

Our staff are prohibited from answering or discussing any specific health-related concern, question, or comment posted on social media sites. We are more than happy to discuss and answer your questions via private telephone calls made to the office or at your scheduled appointments.

Online communication (i.e. email) is an additional option for communication along with telephone, mail, and in-person. It is not meant to replace other forms of communication with the doctor.

Again, please note that email communication should only be used for billing or scheduling appointments only.

I understand that online communication cannot be used for emergencies or time sensitive matters.

I understand that all medical communications carry some level of risk. While the likelihood of risks associated with the use of online communication in a secure environment is substantially reduced, the risks are nonetheless real and very important.

I understand that I am responsible for taking steps to protect myself from any unauthorised use of online communication. Drs Siddi Ganie Inc., it's staff and doctors, are not responsible for breaches of confidentiality caused by an independent party or me.

I understand that online communication should not be used to communicate highly sensitive medical information.

I understand that it is my responsibility to determine if an unanswered online communication was received.

Request for Completion of Forms & Letters

With a few exceptions, all forms and letters that require doctor’s documentation such as those submitted to Home Affairs, disability claim forms, leave forms, work excuses, school excuses, paperwork required from your employer, letters to attorney…etc. require a fee at the time of form submission to the practice. Form fees are determined by office and/or physician and vary from R500 to R2000 depending on the complexity of the form.

The forms will be completed usually within 5 business days. These forms WILL NOT be faxed or submitted to the requesting party unless required by law or the recipient. It will be the patient’s responsibility to pick-up the completed forms from our office.

We understand if you experience frustration regarding form fees. However, all forms, simple or complex, require significant time of the physician and staff to:

review all data on your chart,

ensure that the data written on your form are accurate, and

ensure that all laws are properly followed.

This process takes much time and effort even for what appears as a simple form.

The doctor and our office can be and are in fact often audited by and legally accountable to state and private agencies regarding the data placed on forms on your behalf and must have supporting documentation in your chart. Also, medical aid carriers do not reimburse our office for completing office forms. We want to make sure that the content of the form accurately represents your condition and medical records. Otherwise, the form may be rejected or inaccurate. We hope you understand. If you are unable to afford the form fee or disagree with our office policy, you are welcome to ask any other physician or general practitioner caring for you to complete the form.

All forms are to be submitted with a signed letter authorising release of your medical information before the form is completed.

Treatment of Minors

The parent(s) or legal guardian(s) must accompany all minors. Minors are all patients who are younger than age 18. No minors will be seen or treated unaccompanied. The parent(s) or legal guardian(s) is responsible for any payment and will receive the billing statements. Responsibility for payments for services rendered to the child/children of divorced or separated parents’ rests with the parent who seeks treatment. Any court-ordered judgment must be between the individuals involved, and does not include our facility.

Cancellation Policy

Our staff and Neurologists try their best to keep on schedule and provide prompt service. Please help us keep services prompt. As a courtesy to your neurologist, staff and other patients, please give 24-hour notice to cancel or reschedule your appointment. In the event that you fail to cancel a scheduled appointment and/or are a no-show, i.e. do not show for scheduled appointment without 24-hour notice, you will be billed R250. This fee will be due upon receipt of a statement from our office.

Exceptions may be made for emergency situations such as hospitalisation. Patients who repeatedly miss scheduled appointments may be discharged from the practice.

Sick Certificates

This practice will only provide sick certificates should the specific conditions so warrant. If a diagnosis is provided on the sick certificate, the certificate will only be handed or faxed to you unless otherwise requested by you in writing.

It remains your discretion to disclose your condition or diagnosis to your employer. If you or your employer is considering claiming for a disability, you may be required to disclose the nature and extent of such a disability to your employer and insurance company.

Change of Patient Demographics

Any changes to your medical aid details, name, address or contact phone number needs to be communicated to Drs Siddi Ganie Inc. front office staff at the time of check-in to assure correct billing and contact information is maintained in our records for your appointment. Any denials or non-payments from medical aid carriers based on incorrect and/or invalid information provided to Drs Siddi Ganie Inc. is the patient’s responsibility.

Medical Aid Escalation Process

Should you have any queries or complaints, or perceive that you have been misinformed with regard to your medical aid benefits, the suggested route for these to be lodged is the following:

Your Medical scheme.

Principal officer or Case Manager on-site.

Council for medical schemes (CMS).

Declaration

I hereby acknowledge that I have read and understood the above information prior to having signed and that all information submitted by me is true and correct. I understand that I am under a continuing obligation to advise this practice/practitioner of any changes that may occur after submission of this contract and acknowledge, by signing this contract, that I am legally bound by the provisions of the contract. This contract is subjected to the provisions of the National Credit Act and the HPCSA ethical rules.

I understand that this contract constitutes part of terms and conditions under which professional services will be rendered, in compliance with the Consumer Protection Act.