040 380 80 808 praxis@citymedent.de

Einwilligung Health AG englisch

Born on
Details of the invoice recipient*
Born on
* Parents/guardian/carer for patients under the age of 18, legally incompetent persons or persons with limited legal competency.
More information about how your personal data is processed can be found online at: www.healthag.de/datenschutz

Declaration of consent

The patient states, if applicable represented by legal representatives with sole power of representation:

I accept

  • the disclosure of information necessary for the purposes of billing and the assertion of claims resulting from treatment, in particular data from patient records (name, address, date of birth, findings, treatment data and procedures, etc.), to EOS Health Honorarmanagement AG, Lübecker tordamm 1–3, 20099 Hamburg, Germany (short form: Health AG), and that this information may be processed there;
  • the invoicing by Health AG in its own name and for its own account;
  • the sharing of the aforementioned information, in particular data from patient documentation (see above), to SPV Health Finanzierungs-GmbH, Joachimsthaler Strasse 20, 10719 Berlin, Germany (short form: SPV);
  • he assignment of any claim(s) to Health AG and, for the purpose of refinancing, the further assignment of the claim(s) by Health AG to SPV.

I absolve my practitioner or the practice/clinic (see stamp) and Health AG from maintaining their duty of confidentiality to the extent that this is necessary for the assertion of the claim(s) by Health AG or SPV. I am aware that any objections to the claim(s) are to be raised with Health AG or SPV, and it is possible that details of treatment may need to be disclosed, and that my practitioner or the practice/clinic may be called as a witness in case of a possible dispute with Health AG or SPV.

I also agree that my practitioner or the practice/clinic or Health AG may obtain information concerning my creditworthiness from credit agencies. To this end, for example, CRIF Bürgel GmbH (Radlkoferstrasse 2, 81373 Munich, Germany) may provide any information in its database concerning my address and creditworthiness, including information that is determined using a scientifically recognised mathematical and statistical method, on the provision that my practitioner or the practice/clinic or Health AG has expressed a credible legitimate interest. Address details may be used to calculate probability values.

I give my consent voluntarily and am aware that treatment is not subject to my granting consent. My consent also applies to future treatments and can be revoked by me at any time with future effect by contacting my practitioner or practice/clinic or Health AG. Data processing carried out prior to my revocation and invoices already issued by Health AG shall remain unaffected.

 

 

Explanation of the declaration of consent overleaf

Dear Patient,

We wish to concentrate completely on you and your treatment. For that reason, we have decided to transfer the management of our patient invoices to a trusted partner.
EOS Health Honorarmanagement AG, or Health AG for short, will enable the swift and accurate processing of your invoices. This reduces our administrative work, leaving us more time to care for you.

If you have any questions about an invoice or want to pay in convenient instalments, please contact Health AG.
Your data is in good hands with them. Your data will be treated by the company in accordance with the General Data Protection Regulation (GDPR) and the German Federal Data Protection Act (BDSG). It will not be passed on to third parties.
We need your written consent in order to enable settlement in cooperation with Health AG.
We therefore request that you sign this declaration of consent.

Thank you very much!

Your practice/clinic team