Informed Financial Consent Bariatric Surgery

Informed Financial Consent For Surgery

Full Name *

Date *

Email Address *

What type of procedure are you having? (can be more than one)

GastroscopyBariatric Surgery (Gastric sleeve, Gastric bypass or other revision surgery)

General Statement of Acknowledgement - Gastroscopy *

I understand that my Gastroscopy will be billed directly to my health fund as a no-gap procedure if I am insured.I understand that my Gastroscopy will be either billed directly to Medicare as a bulk-billed procedure when it is being performed as part of a package of care, or else I will be billed a Private Fee for the procedure.I have been given ample opportunity to enquire about any details in these documents regarding my fees for treatment, and have a clear understanding of my fees.I understand and accept that any out-of-pocket or gap fee is payable when booking surgery as a deposit.I understand that the Fee Estimate quoted is valid for 6 months from date of issue.I understand that I will need to obtain fee estimates and invoices from all parties to be involved in my care including the anaesthetist and hospital. It is expected that the costs of the anaesthetist should be around $300 and North West Private Hospital $705.

General Statement of Acknowledgement - Bariatric *

I have received and read the document "Financial Information for Bariatric Surgery".I have been given ample opportunity to enquire about any details in these documents regarding my fees for treatment, and have a clear understanding of my fees.I understand that the Fee Estimate and Bariatric Care Plan Fee quoted are valid for 6 months from date of issue, or for 12 months from when the Bariatric Care Plan Fee is paid in full.I understand that I will need to obtain fee estimates and invoices from all parties to be involved in my care including the surgical assistant, anaesthetist and hospital.

Cancellation Policy - Gastroscopy *

I accept and acknowledge that if I cancel my gastroscopy at short notice within 48 hours of the procedure date, to rebook the procedure the "no gap" fee will need to be paid upfront if insured, or the equivalent of an AHSA health fund "no gap" fee will need to be paid upfront if uninsured, and the fee will be non-refundable.

Cancellation Policy - Bariatric Surgery *

I accept and acknowledge that the $500 deposit, or $500 of the bariatric care plan if the full amount was paid, is non-refundable. I accept and acknowledge that if surgery is cancelled within 14 days of the surgery date, 100% of the deposit fee will be forfeited. I accept and acknowledge that to rebook a surgery date after a deposit has been forfeited, a further deposit of $500 will be due in addition to the bariatric care plan. Refunds will be considered if there are genuine extenuating circumstances.

I am covered for the proposed surgery by a private health insurance fund *

YesNo

Insured Patients' Responsibilities *

I understand that it is my responsibility to pay the account owed to Brisbane General & Obesity Surgery in full at least 14 days prior to my procedure.I acknowledge that it is my responsibility to confirm with my health insurance fund the level of cover that I have and any amount that it will be my responsibility to pay. I acknowledge that it is my responsibility to confirm whether the planned admission or treatment is within a waiting or exclusion period for the policy.I acknowledge that it is my responsibility to confirm with my health insurance fund whether an excess is payable to the hospital for the admission or treatment.I understand that failure to ensure that my treatment is covered by my health insurance may result in significant financial liability for all costs related to my treatment.I consent for my health-fund to be billed directly for my care performed in hospital. This may include for procedures where it may be billed as a "no-gap" or "known gap" procedure.

Uninsured Patients' Responsibilities *

I understand that being uninsured it is my responsibility to pay the account owed to Brisbane General & Obesity Surgery in full at least 14 days prior to my procedure.I understand that it is my responsibility to determine the estimated fees for the hospital.I understand that unforeseen events can occur that can lengthen hospital stay, result in Intensive Care Unit admission, further investigations or consultations that can increase the estimated fees payable to the hospital, radiology or pathology laboratory, or allied health providers.

Patient Declaration *

I am aware the Fee Estimate related to the proposed treatment may change as a result of variations in the actual treatment provided based on clinical judgement at time of surgery.I have been advised that other health professionals may be involved in my treatment and I understand that this estimate does not include their fees or charges unless specifically stated otherwise.I am aware I may receive separate accounts from other service providers associated with my treatment, including from my surgeon, surgical assistant, anaesthetist, hospital, pharmacy, allied health and other physicians who may be involved in my care.I understand that as a private patient I am responsible for all hospital, diagnostic and prosthetic costs that are not covered by my health fund or Medicare. - this can include but is not restricted to pathology, blood tests and medical imaging.The patient or nominee named herein undertake to pay the patient payment as indicated, together with any unforeseen costs which may arise as a consequence of the procedure(s).I agree for eligible follow-up appointments to be "bulk-billed" to Medicare and the benefit to be assigned to Dr Wong or Dr Lim.

I, (Patient's Full Name) *

understand the Financial Information and Fee Estimate that I have been issued, and accept to pay all costs related to my operation as disclosed above and in those documents. I understand that the quoted Fee Estimate is valid for 6 months.

Patient's Signature *

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Date of Acceptance *

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