DISCLAIMER - To be signed by the main member of medical aid / the person responsible for the account of outstanding balances, if different from the main member.

• If I am not a member of a Medical Aid Fund, or if my Medical Aid limit has been reached, it is my responsibility to settle the account or query with my Medical Aid. Most Medical Aids/savings plans only have a limited amount of funds available for psychological services, it is therefore my responsibility to keep myself up to date so as not to exceed my limit.

Prescribed Minimum Benefit (PMB)

• Should you qualify for the necessary diagnosis for PMB to be approved, we will apply to your medical aid at no additional cost to you.
• It is your responsibility to contact your medical aid to ensure that you are aware of how your medical aid PMB and payment procedures apply.
• Medical aids can approve anything from 1 to 15 PMB consultations. These are shared with any psychiatrist/psychologist you may be seeing.
• Some medical aids have existing forms (renewed each year), that is completed by both you and the relevant psychologist. Other medical aids require the relevant psychologist to write an additional motivation.
• These sessions that are approved are 60-minute consultations. Please note that if your session exceeds 60 min, then the minutes are carried over till another 60 min are reached. This is done in your best interest, as a 90-minute submitted consultation will otherwise take away 2 sessions.
• Please check with your medical aid how many sessions you have left.
• Some medical aids require motivation from either your GP or your psychiatrist for additional sessions to be approved.
• When the current year ends, the remaining PMB sessions will lapse, meaning new PMB needs to be applied for each year. The first session in the year is used to evaluate the client and ensure the diagnosis is still correct.

I undertake to pay in full for all professional services by Elonie De Klerk Psychologists practice within 60 days. I agree that in the event of any legal action being taken against me for any amount due by me to Elonie De Klerk Psychologists, for professional services rendered; I am liable and agree to pay all legal costs on the attorney-client scale together with the interest thereon, and all collections costs on any payment made.

• Appointments not cancelled 24 hours in advance will be charged 50% of the cash rate of R1320 and cannot be submitted to medical aid. This will need to be paid before a follow-up appointment can be scheduled.

I have read the above informed disclaimer; I understand and agree to it.