In preparation, please familiarise yourself with the Conditions for Admission and Consent clauses below. The patient / signatory will be required to sign their admission form on the day of admission to hospital.
SUMMARY OF CONDITIONS FOR ADMISSION
There are six (6) Conditions of Admission at the back of the Admission form. The patient / signatory agrees to these conditions when signing the Admission form.
Guarantee of payment
The person signing the form takes full responsibility to pay the account (if the medical aid does not pay). The person signing chooses the address on the front of the Admission form as the one where legal notices, etc. can be served on them. They are also liable for collection costs (attorney fees, tracing fees, interest, etc.).
Jurisdiction
If any legal actions take place, it will be done according to the Laws of South Africa or Namibia, whichever is applicable. It will take place in a Magistrate Court and not in the High Court.
Indemnity
Mediclinic takes no responsibility for the loss or damage of personal items, except if it was handed in for safe-keeping at Reception. If the patient is injured or harmed during his or her hospital stay, as a result of something which the hospital was supposed or not supposed to do, they may sue Mediclinic for no more than R10 million.
Credit Bureau
If a patient or signatory does not pay the account in due time, he or she may be handed over to a credit bureau.
General
The person signing, willingly agrees to the Conditions of Admission. They also agree that they did not provide the hospital with false or incorrect information or knowingly withheld important information.
Severability
If one part of the contract (i.e. clause or section) is found to be legally unacceptable or can't be enforced for whatever reason, then only that clause or section is 'removed' from the contract but the rest of the Admission form still remains valid.
*For the full Conditions of Admission in English and Afrikaans, please scroll down.
CONSENT CLAUSES
Clinical Consent
I hereby authorise the hospital to provide any information of whatever nature concerning my hospitalisation, including but not limited to current conditions/co-morbidities and demographic information to my medical aid fund, managed health care organisation and/or their respective agents dealing with my hospitalisation and to the medical professionals involved in my care including for the administration of their practices and/or to any authorities in respect of patient safety or other clinical quality requirements. Should any of the aforementioned parties also be my employer, then I understand that the information may also be available to my employer.
Survey Consent
Mediclinic continually monitors the quality of its services and therefore conducts patient experience surveys as part of our patient experience programme amongst some of our patients and parents or guardians of patients under the age of 18 (minors), who are willing to participate. We require your consent to provide your personal information to our service partner, who will invite you digitally to take part in our patient experience survey.
Kindly note that your personal information will be treated confidentially and used solely for the purpose of improving our service quality.
UCR Consent
Mediclinic securely stores patient information in a unified record of care (UCR) which is used to facilitate the provision of your care in our facilities. Should you consent, we will provide the care team with a view on your previous encounters of care which includes your treatment, diagnoses and diagnostic results related to treatment you have received at Mediclinic or one of its Subsidiaries. This information will assist your clinical teams in making more informed and safer care decisions.
CONDITIONS FOR ADMISSION
The patient is admitted to the hospital owned and/or operated by Mediclinic (Pty) Ltd("Hospital") on the terms and conditions set out below. Any reference to Hospital shall, where the context allows, include a reference to Mediclinic (Pty) Ltd, its holding, subsidiary and associated companies.
GUARANTEE OF PAYMENT
Any person who signs this admission form on behalf of the patient or as guardian or as guarantor of the patient ("Signatory") or as the patient, whether on admission, during the patient's Hospital stay oron thepatient's discharge from the Hospital:
1. Agrees thereby to be jointly (where applicable) and severally liable for payment of the Hospital account in respect of the services rendered to the patient, including the pharmacy account, notwithstanding any claim arising from a medical aid scheme or insurance cover. Any Signatory shall remain bound notwithstanding that the patient has not signed this admission form.
2. Is expected to have acquainted him/her/themselves with all the terms and tariffs applicable upon admission to the Hospital and to have noted that:
2.1 the daily tariff is in respect of accommodation (including ward stay, meals and general nursing care);
2.2 the full Hospital account (which may include, but is not limited to, accommodation, theatre time, gasses, equipment, pharmacy stock, and miscellaneous items such as telephone use, etc.) in respect of the patient's stay at the Hospital, the services rendered and medication and/or other goods dispensed from the pharmacy is payable in full upon rendering thereof;
2.3 doctors and other medical professionals' fees will be billed separately;
2.4 the terms and tariffs applicable to private patients are accessible on www.mediclinic.co.za or a copy of such tariffs are available via reception; and
2.5 the terms and tariffs for patients covered by medical aid schemes vary. Please communicate directly with the patient's medical aid scheme for the applicable tariffs prior to admission.
3. Undertakes, in the event of an account being unsettled for any reason and being referred to attorneys for collection, to be jointly and severally liable for the payment of all costs on an attorney and own client scale, all collection commission and all tracing costs. All outstanding amounts will be recovered in the following order: attorney's fees, collection commission, tracing fees, interest and lastly capital.
4. Warrants hereby that (if applicable):
4.1 the patient is a bona fide member of the medical aid scheme mentioned herein and his/her membership is valid as at the date of signature of this admission form; or
4.2 the Signatory is a bona fide member of the medical aid scheme mentioned in this admission form, his/her membership is valid as at the date of signature of this admission form, and the patient isa bona fide dependent in terms of such membership;
4.3 there are medical aid scheme benefits available for the patient; and
4.4 that he/she has not been sequestrated and does not suffer from any legal or contractual disability.
5. Authorises the Hospital to present for payment to the medical aid scheme any account owed to the Hospital in respect of the patient, on behalf of the patient and/or Signatory ("Debtor"). Notwithstanding the aforesaid, it is specifically recorded that it remains the Debtor's duty to ensure that all accounts are received by the medical aid scheme timeously. The Hospital shall incur no liability in instances where accounts are not submitted to the medical aid scheme timeously.
6. The hospital's account in respect of the services rendered to the patient will be paid at the hospital with address as indicated on the reverse side of this document.
7. Chooses domicifium citandi et executandi at the address detailed on the front page of this admission form.
JURISDICTION
The legal relationship between the Debtor and the Hospital, and any of their directors, employees, agents and/or representatives (hereafter referred to as "the Hospital et al"), arising directly or indirectly from the admission of the patient to the Hospital or in respect of any treatment administered to the patient in the Hospital, shall be determined exclusively in accordance with the Laws of the Republic of South Africa/Namibia (in whichever country the Hospital is situated, as the case may be) in the Republic of South Africa/Namibia (as the case may be) and furthermore any competent Magistrate's Court in the Republic of South Africa/Namibia (as the case may be), or at the election of the Hospital, the High Court, shall have jurisdiction in all matters so arising, notwithstanding the amount of the cause of action.
INDEMNITY
It is an explicit condition of admission to the Hospital that the Hospital et al will not be liable for the loss of or damage to the personal effects of the patient, except where such effects were handed in for safe custody and a safe custody receipt, issued on behalf of the Hospital, can be produced, and such loss or damage was caused by the Hospital et al's negligent act or omission.
Although the Hospital et al will take care in ensuring the safety and well-being of the patient in the Hospital, subject to all applicable laws, the patient and/or the Signatory agrees that all claims proved against the Hospital et al for loss or damage, including consequential damage or expenses suffered or incurred by the patient and/or the Signatory, arising directly or indirectly from any injury, disability, mental or physical harm (of whatsoever nature) suffered by the patient resulting from any act or omission (of whatsoever nature) by the Hospital et al, shall be limited in quantum to a maximum amount of RlO million, irrespective of whether the claim arises by contract, delict or otherwise and whether for special damages, general damages, consequential damages or any other claims of whatsoever nature.
CREDIT BUREAU
The patient and/or Signatory confirms that the Hospital may provide a credit bureau with all information regarding these conditions for admission and any non-compliance with the terms thereof by the patient and/or Signatory. The patient and/or Signatory confirms that the credit bureau may supply a credit profile and a possible credit rating based on the credit worthiness of the patient and/or Signatory to the Hospital. The patient and/or Signatory have the right to contact such credit bureau, to request the disclosure of his/her credit record and to correct any incorrect information.
GENERAL
No alteration or deletion of any part of this document shall be effective unless the Hospital Manager or his/her authorised representative signs next to each variation or deletion. By affixing his/her signature hereto the patient and/or Signatory confirms that he/she does so willingly and without any duress of any nature and confirms furthermore that he/she agrees to these conditions for admission and that no misrepresentation with regard to the content hereof has been made by the Hospital or any of its employees.
SEVERABILITY
The invalidity or unenforceability of any provisions of this Admission form shall not affect the validity or enforceability of any other provision of this Admission form, which shall remain in full force and effect.
VOORWAARDES VIR OPNAME
Die pasient word in die hospitaal wat deur Mediclinic (Edms.) Bpk besit en/of bedryf word ("Hospitaal") opgeneem ingevolge die bepalings en voorwaardes soos hieronder uiteengesit. Enige verwysing na Hospitaal sal, waar die konteks dit toelaat, ook verwys na Mediclinic (Edms.) Bpk, sowel as sy houer-filiaal- en geassosieerde maatskappye.
WAARBORG VAN BETALING
Enige persoon wat hierdie toelatingsvorm namens die pasiE!nt onderteken, of as voog of as borg van die pasiE!nt ("Ondertekenaar"), of as die pasiE!nt self, hetsy by opname, tydens die pasiE!nt se verblyf in die Hospitaal of met die pasient se ontslag uit die Hospitaal:
1. Stem daartoe in om gesamentlik (waar van toepassing) en afsonderlik aanspreeklik te wees vir die betaling van die Hospitaalrekening ten opsigte van die dienste wat aan die pasient gelewer is, insluitende die apteekrekening, ondanks enige eis voortvloeiend uit 'n mediesefonds skema of versekeringsdekking. Enige Ondertekenaar sal hiertoe verbind bly ondanks die feit dat die pasient nie hierdie toelatingsvorm geteken het nie.
2. Word geag hulself te vergewis het van al die voorwaardes en tariewe van toepassing op toelating tot die Hospitaal en daarop te gelet het dat:
2.1 die daaglikse tarief slegs ten opsigte van verblyf is (insluitende saalverblyf, maaltye en algemene verpleegsorg);
2.2 Die voile Hospitaalrekening (insluitende, maar nie beperk nie tot, verblyf, teatertyd, gasse, toerusting, apteekvoorraad en diverse items soos telefoongebruik, ens.) ten opsigte van die pasiE!nt se Hospitaalverblyf, die gelewerde dienste en medikasie en/of ander goedere deur dieapteek geresepteer, ten volle betaalbaar is na lewering daarvan;
2.3 dokters en ander mediese beroepslui aparte rekeninge sal stuur;
2.4 die voorwaardes en tariewe wat vir privaat pasiente geld, by www.mediclinic.co.za verkrygbaar is, of 'n afskrif van sodanige tariewe by ontvangs beskikbaar is; en
2.5 die voorwaardes en tariewe vir pasiente wat deur mediesefonds skemas gedek word, verskil. Kommunikeer asseblief v66r opname direk met die pasiE!nt se mediesefonds skema vir die toepaslike tariewe.
3. Onderneem om, indien die rekening om enige rede onvereffen is en na prokureurs verwys word vir invordering, gesamentlik en afsonderlik aanspreeklik te wees vir die betaling van alle koste op 'n prokureur en eie-ktient skaal, alle invorderingskommissie en alle opsporingsfooie. Alie uitstaande bedrae sal in die volgende volgorde ingevorder word: prokureursfooie, invorderingskommissie, opsporingskoste, rente en laastens kapitaal.
4. Waarborg hiermee dat (indien van toepassing):
4.1 die pasient 'n bona fide lid van die mediesefonds skema is waarna hierin verwys word en sy/haar lidmaatskap geldig is op die datum van ondertekening van hierdie toelatingsvorm; of
4.2 die Ondertekenaar 'n bona fide lid van die mediesefonds skema is waarna hierin verwys word en sy/haar lidmaatskap geldig is op die datum van onderteking van hierdie toelatingsvorm en dat die pasient 'n bona fide afhanklike ten opsigte van sodanige lidmaatskap is;
4.3 daar mediesefonds skema voordele vir die pasient beskikbaar is; en
4.4 hy/sy nie gesekwestreer is nie en nie onderhewig is aan enige wetlike of kontraktuele vermoensgebrek nie.
5. Magtig die hospitaal om enige uitstaande Hospitaalrekening met betrekking tot die pasient namens die pasiE!nt en/of Ondertekenaar ("Skuldenaar") aan die mediesefonds skema vir betaling voor te IE!. Ondanks die voorafgaande word spesifieke melding gemaak dat dit die Skuldenaar se plig bly om te verseker dat alle rekeninge tydig deur die mediesefonds skema ontvang word. Die hospitaal sal geen aanspreeklikheid aanvaar in gevalle waar rekeninge nie tydig by die mediesefonds skema ingedien is nie.
6. Die hospitaalrekening, ten opsigte van die dienste aan die pasient gelewer, sal by die hospitaal betaal word, waarvan die adres op die keersy van die dokument aangedui word.
7. Kies die adres wat op die voorblad van hierdie toelatingsvorm aangegee is as die domicilium citandi et executandi.
JURISDIKSIE
Die regsverhouding tussen die Skuldenaar en die Hospitaal, en enige van hul direkteure, werknemers, agente en/of verteenwoordigers (hierna genoem "die Hospitaal et al") direk of indirek voortvloeiend uit die opname van die pasiE!nt in die hospitaal of in verband met enige behandeling wat die pasient in die hospitaal ontvang, sal eksklusief in ooreenstemming met die Wette van die Republiek van Suid-Afrika/Namibie (in watter land die Hospitaal ookal gelee is, na gelang van die geval) in die Republiek van Suid-Afrika/Namibie (na gelang van die geval) bepaal word en voorts sal enige regsbevoegde Landdroshof in die Republiek van Suid-Afrika/Namibie (na gelang van die geval) of, by voorkeur van die Hospitaal, die HoE!rhof, beskik oor die jurisdiksie in alle sake voortvloeiend, ongeag die bedrag van die skuldoorsaak.
VRYWARING
Dit is 'n uitdruklike voorwaarde vir Hospitaalopname, dat die Hospitaal et al nie aanspreeklik sal wees vir die verlies of beskadiging van 'n pasiE!nt se persoonlike besittings nie, behalwe waar sodanige besittings vir veilige bewaring ingehandig is en 'n bewaringsbewys namens die hospitaal uitgereik, getoon kan word, en waar sodanige verlies of skade as gevolg van die Hospitaal et al se nalatigheid of pligsversuim veroorsaak is.
Alhoewel die Hospitaal et al sorg sal neem om die veiligheid en welsyn van die pasient in die Hospitaal te verseker, onderhewig aan alle toepaslike wetgewing stem die pasiE!nt en/of die Ondertekenaar toe dat alle eise vir verlies of skade wat teen die Hospitaal et el bewys is, insluitende gevolgskade of uitgawes aangegaan of gely deur die pasiE!nt en/of die Ondertekenaar, direk of indirek as gevolg van enige besering, ongeskiktheid, geestelike of fisiese skade (van watter aard ookal) wat deur die pasient opgedoen is as gevolg van enige doen of late (van watter aard ookal) deur die Hospitaal eta/, beperk sal word tot 'n maksimum bedrag van RlO miljoen, ongeag daarvan of die eis as gevolg van kontrakbreuk, delik of andersins ontstaan en of die eis vir spesiale skade, algemene skade, gevolgskade of enige ander verlies van watter aard ookal mag wees.
KREDIETBURO
Die pasient en/of Ondertekenaar bevestig dat die Hospitaal alle inligting rakende hierdie voorwaardes vir opname en enige nie-nakoming van die bepalings daarvan deur die pasiE!nt en/of Ondertekenaar aan 'n kredietburo mag verskaf. Die pasiE!nt en/of Ondertekenaar bevestig dat die kredietburo 'n kredietprofiel aan die Hospitaal mag verskaf, asook 'n moontlike kredietwaardigheidsbepaling van die pasient en/of Ondertekenaar. Die pasient en/of Ondertekenaar het die reg om sodanige kredietburo te kontak, om die openbaring van sy/haar kredietrekord aan te vra en om enige verkeerde inligting reg te stel.
ALGEMEEN
Geen wysiging of deurhaling van enige gedeelte van hierdie dokument sal effektief wees nie, tensy die Hospitaalbestuurder of sy / haar gemagtigde verteenwoordiger teenoor elke wysiging of deurhaling teken. Deur sy/haar handtekening hierop aan te bring, bevestig die pasiE!nt en/of Ondertekenaar dat hy/sy dit vrywillig en sander dwang van enige aard doen, en bevestig voorts dat hy/sy tot hierdie voorwaardes vir opname instem en dat geen wanvoorstelling ten opsigte van die inhoud hiervan deur die Hospitaal of enige van sy werknemers gemaak is nie.
DEELBAARHEID
Die ongeldigheid of nie-uitvoerbaarheid van enige bepalings van hierdie Toelatingsvorm sal nie die geldigheid of uitvoerbaarheid van enige ander bepaling van hierdie Toelatingsvorm, wat ten volle van krag sal bly, be"fnvloed nie.