TERMS AND CONDITIONS - PREGNANCY
GENERAL TERMS AND CONDITIONS APPLICABLE TO PREGNANCY AND DELIVERY
2021 AGREEMENT
I, the undersigned, hereby acknowledge and accept the following practice rules and regulations:
- I am aware that this contract serves as a notice of practice policy. It is non-negotiable and is a legal document, a binding agreement between myself and Dr Tembisa Tini Inc and that this agreement pertains to all patients of Dr Tembisa Tini Inc unless special circumstances or exemptions have formally been put in writing and personally signed by Dr Tembisa Tini Inc.
- I am also aware that there will be annual increases in practice fees for all consultations, deliveries and procedures, and that unless a formal quotation for a specific procedure is accepted in writing by both client and provider, these cost-increases will apply to all patients (usually effective 1 January of each year).
- By choosing to make use of Dr Tembisa Tini Inc’s services, I declare myself the person responsible for my complete account. I undertake to settle all fees incurred through elective or emergency consultation, deliveries, procedures or care otherwise provided irrespective of my agreement with my medical aid. If there is any delay or dispute (by my insurer or other) regarding payment, I undertake to settle the account personally within 30 days of services rendered.
- If I am a dependant on my medical insurance, I personally take responsibility to inform the main member of this agreement as well as all other decisions or arrangements made with this practice or its affiliated staff, and until the main member agrees to accept responsibility for the account
- I accept full financial responsibility as set-out in this document as well as the practice billing policy.
- I am aware that 2% interest and administrative costs will be charged per month (after 60 days) for all overdue accounts and that legal steps will be taken by the practice with any additional costs incurred to be added to my account.
- I know that for all care, including deliveries and emergencies, this practice is solely affiliated with Life Mercantile Hospital and also that the practice may make use of locum doctors (including male doctors) as per the discretion of Dr Tembisa Tini Inc. I understand that Dr Tembisa Tini Inc is under no obligation to personally attend to my care, and I agree to accept care offered by the locum doctors appointed by Dr Tembisa Tini Inc when she is not personally available to tend to my care
- I do not object to the discreet disclosure of my personal and medical information to relevant parties eg, locum doctors as well as to my medical aid/insurance, mostly through the use of ICD10 and procedure codes.
- Upon signing the practice terms and conditions I have been made aware that all consultations and interaction with Dr Tembisa Tini Inc are subject to electronic storage and copies will be stored in a secure server as part of practice note-keeping for the personal use of Dr Tembisa Tini Inc.
- Dr Tembisa Tini Inc and staff have provided adequate opportunity to enquire about and discuss the billing and payment protocols and I am aware of the consultation and delivery fees
- I have also been made aware that Dr Tembisa Tini Inc does not respond to any enquiries via SMS/WhatsApp and that in case of emergency, I have to directly contact her (or the locum doctor covering the practice) through the emergency telephone number.
- I have chosen to consult Dr Tembisa Tini Inc and sign this agreement as a personal decision, without coercion. I acknowledge that I am under no obligation to consult Dr Tembisa Tini Inc and that there are other caregivers in the Port Elizabeth area to whom she will gladly refer me if requested.