The Patient Payment Agreement Form is a essential document for healthcare providers in New Zealand to establish clear financial arrangements with their patients. This agreement is designed for use when initiating a new patient relationship or updating existing payment arrangements, ensuring transparency in financial obligations and compliance with New Zealand healthcare regulations. The document covers payment terms, fee structures, insurance arrangements, and ACC claims processes, while adhering to the requirements of the Health and Disability Commissioner Act 1994, Privacy Act 2020, and other relevant legislation. It's particularly important for private practices, specialist clinics, and other healthcare providers who need to document payment arrangements with their patients.
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1. Parties: Identifies the healthcare provider and the patient (including full legal names, addresses, and contact details)
2. Background: Brief context explaining the purpose of the agreement for healthcare services payment
3. Definitions: Defines key terms used throughout the agreement including 'Services', 'Fees', 'Payment Terms', etc.
4. Services Covered: Outlines the healthcare services that are subject to this payment agreement
5. Fee Structure: Details the fees for services, including standard consultation rates and additional charges
6. Payment Terms: Specifies payment timing, accepted payment methods, and any immediate payment requirements
7. Patient Acknowledgment: Patient's confirmation of understanding and agreement to the payment terms
8. Default and Late Payments: Consequences of missed payments and late payment procedures
9. Privacy and Information Handling: How patient's financial and personal information will be handled and protected
10. Term and Termination: Duration of the agreement and conditions for termination
11. Execution: Signature blocks for all parties with date fields
1. Third-Party Payments: Include when insurance companies or other third parties are involved in payment
2. Payment Plan Details: Include when offering installment payments or special payment arrangements
3. Guarantor Details: Include when someone other than the patient is guaranteeing payment
4. ACC Claims: Include for services that may be covered by ACC (Accident Compensation Corporation)
5. Cancellation Policy: Include when specific cancellation fees or policies apply
6. Special Discounts: Include when offering community service cards, student, or other discount arrangements
7. Direct Debit Authorization: Include when automatic payments are being set up
1. Schedule 1 - Fee Schedule: Detailed breakdown of all possible fees and charges for services
2. Schedule 2 - Payment Plan Terms: Specific details of payment plan options including installment amounts and dates
3. Schedule 3 - Direct Debit Terms: Terms and conditions for direct debit arrangements if applicable
4. Appendix A - Privacy Policy: Detailed privacy policy regarding handling of patient financial information
5. Appendix B - Cancellation Policy: Detailed cancellation and refund policies
Authors
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Medical Services
Dental Services
Allied Health
Mental Health Services
Physiotherapy
Private Practice
Public Health
Community Health
Specialist Medical Services
Relevant Teams
Administration
Finance
Front Desk
Operations
Legal
Compliance
Patient Services
Accounts Receivable
Practice Management
Clinical Operations
Relevant Roles
Practice Manager
Healthcare Administrator
Medical Office Manager
Financial Controller
Accounts Receivable Officer
Medical Receptionist
Healthcare Provider
Clinical Director
Business Manager
Compliance Officer
Legal Counsel
Operations Manager
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