ACCOUNT SETTLEMENT & TREATMENT RESPONSIBILITY & CONSENT FORM

I, the undersigned patient, request care and treatment from this Mediclinic Middle East facility or any of the other hospital(s) or clinics in the Mediclinic group in the United Arab Emirates. I consent to and authorise the following: 

General consent

By signing below, I authorise this Mediclinic Middle East facility or any of the other hospital(s) or clinics within the Mediclinic group in the United Arab Emirates and their staff to conduct any diagnostic examinations, tests and procedures and to provide any medications, treatment or therapy necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries. I understand that it is the responsibility of my healthcare providers to explain the reasons for any particular diagnostic examination, test or procedure, the available treatment options, the common risks, anticipated benefits associated with these options, and alternative courses of treatment. 

Release of personal and medical information

I understand that the email address and mobile number that I have provided on the registration form will be used as a communication tool between this Mediclinic Middle East facility or any of the other hospitals or clinics in the Mediclinic group in the United Arab Emirates and I.  

On completion of this form I hereby authorise the clinic/hospital to provide any information of whatever nature concerning my treatment, including but not limited to current conditions/comorbidities to my insurance carrier or third party payer, for the purpose of determining benefit entitlement and to process payment, therefore taking responsibility for the financial settlement of my medical bills. 

Mediclinic may disclose my name, email address and whether I am a medical or surgical patient to a contracted third party outside the UAE for the purposes of conducting quality assurance analysis on behalf of Mediclinic, and such contracted third party may disclose this information if authorised or required by any applicable laws or regulatory requirements in the United States of America. This information will be stored and/or processed electronically in accordance with the relevant privacy rules and regulations in the UAE.  this Mediclinic Middle East facility or any of the other hospitals or clinics in the Mediclinic group in the United Arab Emirates is obliged by federal regulations to submit certain patient data/information and I hereby give consent for the use of my information as a statutory requirement. 

I also acknowledge that this consent is subject to the laws and jurisdiction of the United Arab Emirates. 

Release of Medical Test Report

Routine medical test reports requested by the patient/guardian via telephone or e-mail address may be released as an unencrypted report to the e-mail address given by the patient to register in the Mediclinic’s system.  However, the report will be released as aforesaid only on the fulfilment of all the following conditions:

1.  The patient/guardian requesting such a report will have to correctly  state the e-mail address registered in Mediclinic’s system, and

2. Correctly answer any two of the following security questions.

• Mother’s maiden name

• Patient’s date of birth 

• Patient’s Emirates ID number

• Details of patient’s last visit 

I hereby confirm that the e-mail address provided by myself in the registration form is correct and I have exclusive access to the e-mail address I have provided to Mediclinic. Therefore Mediclinic has no further obligation/responsibility to verify this e-mail address I have provided and to which any release of information for routine unencrypted medical test report I may request, will be sent.  

I also hereby agree and confirm that Mediclinic will not be held responsible or held liable for any cost or consequences, for providing my routine unencrypted medical test report to me, or to my guardian as enquired/requested through a telephone call/ e-mail, after verifying the correctness of the aforesaid security questions. 

Valuables

I acknowledge that this Mediclinic Middle East facility or any of the other hospitals or clinics in the Mediclinic group in the United Arab Emirates is not liable for the loss or damage of any money, jewellery, documents or other articles of value. 

Financial Agreement

Within the expected time frame during their clinic/hospital visit or stay, clients are required to take personal responsibility and meet any financial obligation towards this Mediclinic Middle East facility or any of the other hospital(s) or clinics in the Mediclinic group in the United Arab Emirates regardless of the mode and source of payment (i.e.: self-paying, insurance company, sponsoring company, other). In cases where an estimated charge has been given, the deposited amount is utilised against accrued charges or a proportion of same. Kindly note that the estimated charge may differ from the final account depending on the actual services rendered. Clients are therefore responsible for settlement of differential costs. In cases whereby settlement of treatment cost has not been approved by an insurance agreement, sponsorship or third party payer, the client is required to take full responsibility and settle accounts. 

I have read and understood and accept the above terms and conditions, and agree to abide by said requirements herewith towards this Mediclinic Middle East facility or any of the other hospitals or clinics in the Mediclinic group in the United Arab Emirates. I have read the details on my/the patient’s registration form and confirm that they are correct.