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.
