IHD029 PATIENT INFORMATION FORM intercare Sub-Acute Hospital Day Hospital Date: ‘Account ne. File ne. Case Details ‘Admission date: ‘Admission time: Surgeon / Attending doctor: Referring de Patient's Personal Detai Tie nila First names: Surname: 10 number: ssport Numbe Gender: Date of Birth Language Allergy Nationality Occupation: Ethnic Group: Residential Address: Postal Address: Postal code: Postal code: Tel. Works cellphone Patient's Employer Details Employer Name: Employer Address: Postal code: Employer Telephone Employer Registration No: Employer VAT no Employer E-mail: Employee number: Next of Kin Details Next of Kin Name: Next of Kin Address: Postal code: Next of Kin 10 No. Tel Work Cellphone: Relationship ‘Contact person (if different from next of kin: Contact person name: Tel. Home: Te. Works Cellphone: Relationship: Medical Aid name: Medical Aid option: Medical aid number: Person Responsible for Payment ‘Member Surname: ‘Member Full Names Member Tie: Tel, Home: Cellphone: Member Occupation: Residential Address: Postal code: Member ID ne: ‘Member Email ‘Member Initia Tel Work: Fax no. Postal address Postal code: Beneficiary relationship:IHD029 TERMS AND CONDITIONS OF ADMISSION Uhereby gree 1.1, “Account” mean the Ratement of acount proceed by intrcre in respect ofthe treatment and care given tothe pinta the faci, 12 “fal meane tne nterereSub-Acte or Bay hora stusted 3 14 “Patient” means te patent patent’ parent or guardian authorised person andor person responsible for payment ofthe patent's scour ether agench or por 1.6 "Senicer” mean alte testrent andl are received by the patient athe fcity ineuding medication 2) _Thatthe corr aetacated th athe vice to be rendre athe fait wer uly explaines to me 23. Topay the account promply in accordance with the aif args prevaling the cy seal seneme or ay th party such the Comms one or Oeeopatinal ures and Deas in terms of injures 25. Thatshould payment net ake place on ot before the 30" dy after receipt ofthe account mes atthe maximum permisible ate hat may be charged 26 Tograntinteratepermision send all accounts tet tothe patients mesial scheme if apaliabe) for payment 2). Tograntintercare pemison to nde approntiste dagrosc codes {COTO codes} on al acount. Lunderstana tna fhe accounts dono ied CD10 {eas the mel! scheme sal not be lable sete ary accounts or provide any bene in respect ofthe series fendered {hs, | shall stil remain personaly responsible for payment ofall anor any accounts payabie. . 24 That the account relates any te scommodalion, procedure sed medicine chefger and without ting the gneraiy ofthe sencshern mentioned, ides the chrge or doctors pathology falology and sil ther 3 pry sence provide’ which serces shal be bled separtey by th retort 3 ary sence prover the patient or he oatents ager 230. Ththeminmar urges be for ore day, ng might 2 ona ary part rea lb cle oon al day “ by any other person alrected to make the recovery irom the patent " 51 Thatthe patent's erat bureau record maybe checked in oder infor the decsion to grant eateries, 2s wells report on non-payment of any 22. That the naff andlor agen of intecie or any attending doctor or health care profesional, may dove the nature of inslopersionprocedure per formed on he potientrestment snd cre recived, oven lagnons coder )CBI0 coat) ana al ana ary rears ar copies 0 rear inelssan thereto tothe patents agent. 23, Thatallpatient recor remain the property of nterare and shale etained fora maximum period of yar. 34 Thatnether iterate rors employes o agents shal be esporsbl ols of tone, valuables or any athe rope belonging oof n the possesion Fhe patient or atekeping by irtrcre, of darage to sh goods however Suh 5 of Samrage may ae 351 "Shallnt be fable tothe patent ore patents agent fray nun, nes harm los consequent los anlar damages of whatsoever nature vihatoerer nature, ncaing but nat ime to negligence 252. Donor terrentine equipment andlor machinery ned andlor wed by IL The machinery andor equipment is wed ss" and inereare roves fo waranes of ay Kind that regerdInecare makes no represeation or watfanty regaring the acura) and relly sf any norma omsupmled' vercae bythe manufacturer of such machinery andor equipment ners can atepe na ferporisiy for any damage jy, Ines or death caused to o sure by any person ws Yel of eny of ts macrinety enor eaugmetfaing. Ison te set uraerstandng Edscceptance ot altheprovsons on chr dicaimer cave thst nterereaceptrsne sumiion af she pant ace 26 Thate pret erpatent eaten under edmaon, snunaon oan rane rr a thee proces went cnet byte 37 That re polient apres to aide by any pole ofintercaraine act with oper lo ay ue tha enforced forthe protection and cave of is patients ‘ich ana smoking ether hen n sesgnate seat 34 That the paent hereby cede to Inereae al othe patents ight ile and interes in an to any benels, monies andlor medal surance payernts ue and ening the asters othe patent gent fr sl veces rendered sna dines rppied by intercrearing ut ar he patent amision to 533, Thata bleed ex or ary other medical examination including atest fr HIV anor Hepat 3 maybe performed onthe paint i vegarded as neces ‘aryortdvibie oy mereare inthe nterant ofthe heath and safety of he everest raf aver natant admired tote fait ane content such {Si er tamination a erey given andthe taking os loo eine rom ie pate suai be ree florea prpoe. Te sara ‘srasallbe made known any to he pent the patients agent arr the patients doctor subject tote pants wren onsen pateint’s stay of treatment at the fail, hal be Interpreted in accordance with and be Subject to and governed excivsively by the laws of the Republic 4:1 Tosubmitto the unsdicion ofthe appropriate magstvate’s cou in respect fal actions, ether proceedings andor dsptes ring out ofthis agreement Indin respect of any mater arin vom he pave ay or restart the fact terpecne of ha amount hwo 2212 Thatthe addres arndeated an the aemiion orm under the secion“PertonResposbi for Payment rchaven wry domiim Gtand et exectand Toni that have Yad and scape Ter ad condos of s0rson Signed on 20 * Slgraive PatenUauthorsed personparenuguarden ce. miner) Slgratrepevon responsible for payment Fill nara and rarrame of patienvawthoried peronpareigaralan Fall names and sumame of pean responsibe Yor parent