The patient is admitted to the Kiaat Private Hospital (Ply) Ltd (“Hospital”) on the terms and conditions set out below. Any reference to Hospital shall, where the context allows, include a reference to Kiaat Private Hospital (Ply) Ltd, its subsidiaries and associated companies. GUARANTEE OF PAYMENT Any person who signs this admission form as the patient, or on behalf of the patient or as guardian or as guarantor of the patient (“Signatory”), whether on admission, during the patient’s Hospital stay or on the patient’s discharge from the Hospital:
- 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 scheme, third party funder or insurance cover. Any Signatory shall remain bound notwithstanding that the patient has not signed this admission form.
- Is expected to have acquainted him/her/themselves with all the terms and tariffs applicable upon admission to the Hospital and, specifically, to have noted that:
- The daily tariff is in respect of accommodation (including ward stay, meals and general nursing care);
- 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;
- Doctors and any other private healthcare professionals’ fees will be billed separately;
- A copy of the terms and tariffs applicable to private patients are available at the Hospital’s reception; AND
- The terms and tariffs for patients covered by medical schemes/third party funders vary. Please communicate directly with the patient’s medical scheme/ third party funder for the applicable tariffs QdQ.r to admission.
- Warrants hereby that (if applicable):
- The patient is a legitimate member of the medical scheme/third party funder mentioned in this admission form, and his/her membership is valid as at the date of signature of this admission form; OR
- The Signatory is a legitimate member of the medical scheme/third party funder mentioned in this admission form, his/her membership is valid as at the date of signature of this admission form, and the patient is a legitimate dependent in terms of such membership.
- There are sufficient medical scheme/third party funder benefits available for the patient; AND
- That he/she has not been sequestrated and does not suffer from any legal or contractual disability.
- Authorises the Hospital to:
- Disclose to the medical scheme/third party funder the nature of the patient’s illness and/or any operations or procedures performed on the patient, including the relevant diagnosis and procedure codes (i.e. CPT/ICD/SADA codes) for purposes of processing an account; AND
- Present for payment to the medical scheme/third party funder 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 agreed that it remains the Debtor’s duty to ensure that all accounts are received by the medical scheme/third party funder timeously. The Hospital shall incur no liability in instances where accounts are not submitted to the medical scheme/third party funder timeously.
- Undertakes. in the event of an account being unsettled for any reason:
- To pay interest calculated at the rate of 2% per month on any amounts due after 30 days of the patient’s discharge: AND
- Where the account is 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.
- Chooses domicillium citandi et executandi (the physical address where legal notices may be sent) at the address provided in this admission form.
The legal relationship between the Debtor and the Hospital, and any of their past or present directors, employees, agents and/or representatives (“the Releasees”), 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 in the Republic of South Africa and, furthermore, any competent Magistrate’s Court in the Republic of South Africa, 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.
DISCLAIMER OF LIABILITY IN RESPECT OF PRIVATE PROPERTY
It is a condition of admission to the Hospital that the Releasees will not be liable for the loss of or damage to the property. personal effects or monies (property) of the patient. except where such property was 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 negligent conduct on the part of the Releasees.
LIMITATION OF LIABILITY IN RESPECT OF INJURY OR HARM
The patient and/or the Signatory agree that the Releasees’ liability for any and all claims arising directly or indirectly from any injury or harm of whatsoever nature suffered by the patient and/or the Signatory. howsoever caused, proved against the Releasees for loss or damage. including consequential damage, or expenses suffered or incurred by the patient and/or the Signatory. will be limited to and will never exceed the indemnity payable by the Hospital’s professional indemnity insurance in respect of such claim.
The patient and/or Signatory confirm 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 confirm 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.
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.
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.