The responsible person hereby agrees as follows:
                       
1. That (s)he is liable for the dietetic services rendered by the dietitian, and to the extent that it is applicable, (s)he is the parent/legal guardian of the person to whom the services were rendered.
                       
2. To pay promptly the account of the dietitian in accordance with the tariff of charges prevailing   in the dietitian's practice, or as agreed between parties, and in the manner in which parties have agreed.
                       
3. To settle the dietitian's account timely and in full, as agreed, irrespective of contracts / agreements / arrangements (s)he may have with any medical scheme or third party.
                       
4. Should the account not be settled within 30 business days after the dietetic services were rendered by the dietitian, interest will thereafter be charged on any outstanding amount at a rate of 2% per month until the date that the account is settled in full.
                       
5. Should the dietitian institute legal action against the responsible person or hand the account over to a debt collector agent for recovery of any outstanding debts, to pay all costs, including attorney and own client costs, collection fess and tracing fees.
                       
6. It is acknowledged that, in accordance with the provisions of Section 53(1) of the Health Professions Act of 1974 (duly amended) and Section 6(c) of the National Health Act 61 of 2003, the costs associated with all dietetic services rendered by the dietitian, treatment and/or procedures have been discussed and were fully explained to the responsible person and/or patient, to the extent required in law and professional ethics.
               
7. In accordance with legal requirements the dietitian is granted permission to disclose any information about the responsible person and/or the patient, including medical information and/or diagnostic codes, to relevant third parties (such as a funders, administrators, switching companies, and the like for purposes of processing payment of accounts in respect of dietetic services rendered to the responsible person/the patient; as required by a situation. The responsible person and/or patient have been informed that, in certain circumstances, such as disclosure of ICD_10 codes, the exact consequences of disclosing such information is unknown to the dietitian and that information relating to these consequences must be obtained by responsible person and/or patient from the third party to whom the information is disclosed.
                       
8. The responsible person and/or patient agree that the dietitian may:
*make enquiries to confirm any information provided by the responsible person and/or patient;
*seek information from any credit bureau when assessing the responsible person and / or patient's application for credit, or at any time during his/her continuing indebtness to the dietitian including tracing or confirming his/her whereabouts
*disclose the existence of his/her account to any credit bureau, sharing both positive and negative payment information about such account.
                       
9. The consultation fee charged is based on the Ethical Tariff suggested by the Health Professions Council of South Africa.
                       
10. The responsible person and/or patient should contact the dietitian immediately should no account be received 30 (thirty) days after consultation.

 

Release of medical information

Authorization to pay benefits to dietitian: I hereby assign payment directly to Nutritious Living, for dietetic benefits, otherwise payable to me for services described, but not to exceed my indebtness to Nutritious Living, for those services
                       
Medical aid information release authorization: I hereby authorize Nutritious Living to release any information required in the course of my consultation to my referring practitioner
                       
Financial agreement: Upon acceptance of these terms I understand that I am responsible for all fees, regardless of medical aid coverage.