Special Options Contract (eng, PDF)
Transcription
Special Options Contract (eng, PDF)
(Affix patient data label here) If no label is available: Name: Forename: Admission date: Medical insurance: Insurance status: M DoB: Time: F R The Regensburg University Hospital and the above-named patient hereby agree a Special Options Contract on the provision of separately billable special options in keeping with the the general contract conditions (AVB) and the standard charge scale. The following special options have been agreed (check as applicable): The services of all doctors of the hospital involved in the treatment, if these doctors themselves (private doctors) or the hospital are entitled to charge for their services separately, including the services of any outside doctors or medical facilities on whom they may call (private medical care). Charges follow the currently valid version of the standard charging scale for doctors or dentists. Treatment in a single room. € 40,00/day Accommodation and full board for an accompanying person without medical necessity. € 45,00/day plus VAT Should the private doctor be unavailable for unforeseen reasons, the patient agrees to be treated by his or her regular substitute. Department/Private doctor Regular substitute Specialist fields Department of Anaesthesia Prof. Dr. Bernhard Graf PD Dr. Barbara Sinner PD Dr. York Zausig Cardio-thoracic surgery Prof. Dr. Thomas Bein Operative intensive care medicine Dr. Christopher Prasser Vascular surgery; trauma surgery Dr. Dirk Lunz Cardio-thoracic surgery; intensive care medicine PD Dr. Thomas Metterlein Head and neck Dr. Jens Kramer Anaesthesia outside operating room Dr. Gabriel Roth Oral and maxillofacial surgery Dr. Martin Kieninger Neurosurgical intensivemedicine Dr. Christoph Lassen Pain clinic Dr. Michael Dittmar Ophthalmology Dr. Philipp Prahs Cornea Prof. Dr. Herbert Jägle Strabismus; Neuro-ophthalmology; orbita; juvenile opthalmology PD Dr. Isabel Oberacher-Velten Glaukoma Dr. Theresa Barth Eye lids PD Dr. Andreea Gamulescu Retina Prof. Dr. Stefan Fichtner-Feigl Splanchnic and transplantation surgery Dr. Sabine Kümmel Department of Surgery; proctology Department of Ophthalmology Prof. Dr. Horst Helbig Stand: Juli 2016/ SAP 9200261 Department of Surgery Prof. Dr. Hans Schlitt Department of Vascular Surgery Prof. Dr. Piotr Kasprzak PD Dr. Karin Pfister Department of Dermatology Prof. Dr. Mark Berneburg Prof. Dr. Ulrich Hohenleutner Prof. Dr. Sigrid Karrer Wards Dr. Teresa Jeaeger Outpatients Dr. Sebastian Haferkamp Oncology Department/Private doctor Regular substitute Specialist fields Ear, Nose, and Throat Department Prof. Dr. Jürgen Strutz PD Dr. Pingling Kwok Prof. Dr. Thomas Kühnel Dr. Jose C. Pérez Álvarez Dr. Hermann N. Hilber Prof. Dr. Holger Gassner Prof. Dr. Peter Kummer Department of Cardio-thoracic Surgery Prof. Dr. Christof Schmid Prof. Dr. Michael Hilker Dr. Reinhard Kobuch Aortic surgery; valve surgery Dr. Andreas Keyser Pacemaker/ICD Implantation Dr. Leopold Rupprecht VAD programme Prof. Dr. Stephan Hirt Heart transplants Department of Thoracic Surgery Prof. Dr. Hans-Stefan Hofmann Dr. Reiner Neu Department of Internal Medicine I Prof. Dr. Martina Müller-Schilling Dr. Ina Zuber-Jerger Oncology Endoscopy Dr. Tanja Bergmann Endocrinology Prof. Dr. Martin Fleck Rheumatology Dr. Gisela Wölfel CIBD (chronic inflammatory bowel disease); ultrasonics Dr. Stephan Schmid Intensive-care medicine PD Dr. Kilian Weigand Hepatology PD Dr. Michael Selgrad Infectiology Prof. Dr. Dierk Endemann Cardiology Prof. Dr. Christian Schulz Pneumology PD Dr. Thomas Müller Intensive-care medicine Prof. Dr. Marcus Fischer Emergency reception Dr. Ekrem Uecer Rhythmology Prof. Dr. Michael Arzt Sleep laboratory Department of Internal Medicine II Prof. Dr. Lars S. Maier Department of Nephrology Prof. Dr. Bernhard Banas Prof. Dr. Carsten Böger PD Dr. Tobias Bergler Dialysis and intensive-care medicine Dr. Daniel Zecher Nephrological ward Dr. Yvonne Ehrl Outpatients Department of Psychosomatic Medicine Prof. Dr. Thomas Loew Dr. Alexandra Lange Department of Internal Medicine III Prof. Dr. Wolfgang Herr Prof. Dr. Ernst Holler Stem cell transplantation Haematological intensive care Dr. Simone Thomas Hämatologiscal ward Dr. Matthias Grube Oncological ward Dr. Joachim Hahn Oncological systemic therapy Dr. Martin Vogelhuber Psychotherapy Dr. Christina Hart Psychosomatic primary care Dr. Michael Rechenmacher Palliative medicine Department of Paediatrics and Juvenile Medicine Prof. Dr. Michael Melter Dr. Birgit Knoppke Paediatrics; hepatology Dr. Jürgen Kunkel Paediatric Intensive care and emergency medicine Dr. Dirk Grothues Paediatric sonography Department of Paediatric Haematology, Oncology and Stem-cell Transplantation Prof. Dr. Selim Corbacioglu PD Dr. Jürgen Föll Department of Cranio- and Maxillo-facial Surgery Prof. Dr. Dr. Torsten E. Reichert PD Dr. Dr. Ulrich Wahlmann paediatric gastroenterology and Department/Private doctor Department of Neurosurgery Prof. Dr. Alexander Brawanski Department of Neuropathology Prof. Dr. Markus Riemenschneider Department of Radiotherapy Prof. Dr. Oliver Kölbl Department of Nuclear Medicine Prof. Dr. Dirk Hellwig Regular substitute Dr. Odo-Winfried Ullrich Dr. Sylvia Bele Dr. Christian Doenitz Dr. Monika Friedrich Dr. Max Lange Dr. Karl-Michael Schebesch Prof. Dr. Jürgen Schlaier Specialist fields Tumor and vascular surgery Neurosurgical Intensive care medicine Spinal surgery Paediatric neurosurgery Electrophysiology; neurology Tumor and vascular surgery Funktional neurosurgery; pain therapy Dr. Saida Zoubaa Dr. Fabian Pohl Dr. Jirka Grosse PD Dr. Jörg Marienhagen MUDr. Karin Menhart Department of Trauma Surgery Prof. Dr. Michael Nerlich Dr. Carsten Neumann PD Dr. Michael Müller Prof. Dr. Peter Angele Dr. Christian Pfeifer Dr. Antonio Ernstberger PD Dr. Johannes Zellner Dr. Paul Schmitz Dr. Michaela Huber Dr. Florian Baumann Dr. Werner Krutsch Department of Hand and Reconstructive Plastic Surgery Prof. Dr. Dr. Lukas Prantl PD Dr. Jürgen Dolderer Department of Clinical Chemistry and Laboratory Medicine Dr. Petra Lehn PD Dr. Wulf Schneider Dr. Susanne Heimerl Department of Transfusion Medicine Dr. Norbert Ahrens Dr. Robert Offner Department of Infectiology Prof. Dr. Bernd Salzberger Dr. Gabriele Birkenfeld Department of Microbiology and Hygiene Prof. Dr. Dr. André Gessner Prof. Dr. Barbara Schmidt PD Dr. Wulf Schneider Department of Radiology Prof. Dr. Christian Stroszczynski Prof. Dr. Andreas Schreyer Prof. Dr. Gerhard Schuierer Prof. Dr. Okka Hamer Prof. Dr. Ernst-Michael Jung PD Dr. Peter Heiss Prof. Dr. Dr. Walter Wohlgemuth PD Dr. Philipp Wiggermann PD Dr. Patrick Hoffstetter Department of Operative Dentistry and Periodontology Prof. Dr. Wolfgang Buchalla Prof. Dr. Kerstin Galler Department of Orthodontics Prof. Dr. Dr. Peter Proff Dr. Anita Castro Laza Department of Prosthetic Dentistry Prof. Dr. Gerhard Handel Prof. Dr. Michael Behr Conventional nuclear medicine (including SPECT/CT, apart from thyroid); bone and joint therapy Thyroid diseases PET/CT; SIRT therapy; Paediatric nuclearmedicine Spinal surgery Navigation and robotics Knee surgery Shoulder surgery Foot surgery Cartilage and joint surgery Pelvic and hip surgery Interdisziplinary emergency care Paedriatic Traumatology Sports Traumatology Laboratory and transfusion medicine Virology Bacteriology Neuroradiological diagnostics and intervention: Neurosurgery; ENT; Ophthalmology; MCG (all procedures), CNS-diagnostics, emergency (CT/MRI/angiography and intervention) Cardiopulmonary diagnostics (CT, MRI, CTbased interventions) Ultrasonic diagnostics und gynaecological radiology; special procedures (all modalities) Abdominal radiology and general radiology (all procedures) Vascular medicicne and interventional radiology (all procedures); Centre for Vascular Anomalies Surgical x-ray including interventional procedures Musculoskeletal diagnostics (all procedures) The patient hereby agrees to all data necessary for billing purposes being passed to an external billing agency. Notes: 1. The separately billable special options agreed between the hospital or, in the case optional medical care, private doctors and the patient, will be provided within the limits of the available personnel and material resources, in such a way that the general work of the hospital is not disturbed. 2. The hospital or, in the case optional medical care, private doctors can refuse special options to patients who have not paid the costs of a previous hospital treatment, or paid these after their due date. 3. The hospital or the private doctors can temporarily suspend provision of special options without notice whenever and for as long as this is necessary to ensure the provision of general hospital care to other patients; the patent can cancel the agreement at any time, the agreement terminating at the end of the day following cancellation; either party can cancel the agreement without notice for good cause. 4. The hospital and the private doctors can require appropriate advance payments or part payments. 5. Transfer of costs: The costs of special options are not covered by German statutary health insurance policies (gesetzliche Krankenversicherung). Patients receiving special options are direct-payers, and obliged to cover the costs themselves. Patients are advised to ascertain in advance if these costs are covered by a private medical ensurance, by an employer (Beihilfe) or by any other agency. 6. In the case of separately billable care by private doctors, it is not possible to contract the care of only one private doctor (§ 17 KHEntgG). An agreement about separately billable medical care extends to all the doctors of the hospital involved in the care of the patient who are are entitled to charge separately for in-patient, out-patient, pre-admission or postdischarge treatment (§ 115a SGB V), including services by doctors and medical institutions outside the hospital which are arranged by them. This applies also if the hospital itself charges for treatment by a private doctor. 7. Disclaimer of liability in case of separately billable care by private doctors: In the case of separately billable care by private doctors, the hospital is contractually obliged only to provide accommodation, meals and nursing services. Only those doctors entitled to charge for their services separately are party to the special options contract. The hospital accepts no liablility either in contract or in tort for mistakes by private doctors. The private doctor is personally responsible for providing the services to which he or she has agreed, and he or she alone is liable. This applies also to mistakes made by auxiliaries (for example subordinate doctors or doctors consulted for a second opinion) whom he or she may call upon. The hospital has liability for those medical services for which it itself charges. Date Signature of Hospital Staff Member Patient (in the case of minors: parent or guardian) or representative with power of attorney (name and address in block capitals)