Treatment conditions form We have recieved your entry form. Would you please fill in this form as well? Your surname(Vereist) Your initials(Vereist) Day of birth(Vereist) MM slash DD slash JJJJ Your email address By sending this document the patient agrees with: • GGZ Veenendaal processes personal date for the purpose of the treatment (read more in Dutch op de website van GGZ Veenendaal • the treatment agreement applies for the course of intake, treatment and administrative closure. When the treatment has insufficient effect or when the given care does not fit the expectations of the client or GGZ Veenendaal, both can cancel the agreement, even without consent • GGZ Veenendaal can send an invoice when the client does not cancel an appointment at least 24 hours in advance (no show regulation). See our brochure for the amount • During treatment the privacyregulation and tariff set by the health insurence are applied. • GGZ Veenendaal can look into prior information, when applicable • when it concern a client younger than 16 years, both parents or a legal representative must grant persmission and cooperate. • anonymous information is sent to the NZa; these data are not reducible to youClient agrees seperately that (you are not obligated):GGZ Veenendaal can ask for more information from the referrer (mostly the family doctor)(Vereist) yes no GGZ Veenendaal is allowed to inform the family doctor(Vereist) yes no GGZ Veenendaal is allowed to inform the health insurance,if wanted by them in case of material control procedures(Vereist)De zorgverzekeraar kan artsen vragen onze dossiers te controleren. yes no The data in the medical files can be checked during internal or external audits. Secrecy is guaranteed(Vereist) yes no I have read the above and agree(Vereist) I agree Δ
