Treatment agreement
Gooische Praktijk voor Logopedie
Dear client, parent/guardian,
In accordance with the Medical Treatment Agreement Act (WGBO), various aspects of care within the client-provider relationship are regulated. This law is based on a relationship of trust in which the client and the speech therapist consult and make decisions together on an equal footing. Requirements are set regarding the provision of information, consent, and access to information. To comply with these legal requirements, this treatment agreement has been drafted.
Treatment and exercise appointments
You will be assigned a fixed treatment time, which will, in principle, take place weekly at the same time. We kindly ask you to inform us of any changes in a timely manner. In case of cancellation, you must notify us by phone or WhatsApp at least 24 hours before the scheduled appointment. For appointments on Monday, you must cancel by the preceding Friday before 5:00 PM. For each subsequent appointment, a new cancellation is required. If an appointment is canceled too late or if you do not attend without notice, the costs of the missed appointment will be charged to you, as these are not covered by your health insurer. The rate for missed appointments is determined according to the guidelines of the Dutch Healthcare Authority (NZa). The practice reserves the right to terminate treatment when the treatment goals have been achieved or if payment terms are not met. The speech therapist may also decide to terminate the treatment if you miss more than two appointments without notice.
Payment terms
Speech therapy care, including assessment and treatment, is covered by the basic health insurance package and is fully reimbursed. Costs for additional reporting, other than to the referrer, or for consultations with third parties upon request, will be charged to the requesting party. Gooische Practice for Speech Therapy adheres to the payment terms according to the guidelines of the Dutch Association for Speech Therapy and Phoniatrics (NVLF).
Although speech therapy care has been directly accessible since August 1, 2011 (Direct Access Speech Therapy - DTL), this procedure requires extensive screening. Therefore, Gooische Practice for Speech Therapy has decided to require a referral from the general practitioner for every new client.
Consent for data exchange
If you have been referred by a physician, contact with this referrer is considered self-evident, and explicit consent for sending a report to the referrer is not required. For the exchange of information with other professionals or involved parties, other than the referrer, your explicit consent is required by law. This exchange takes place solely to optimize the speech therapy care and treatment of you or your child. By signing this form, you give consent for the aforementioned data exchange and agree that these data may be shared in the context of treatment and the well-being of the client.
Retention periods for patient data
Patient data will be retained for a period of 15 years in accordance with the WGBO. After this period, the data will be destroyed.
Quality assessment
Since August 2014, speech therapy practices may be evaluated for the quality of their care. This assessment is carried out by an independent agency. Your patient data may be reviewed during this evaluation, with your data being protected by the General Data Protection Regulation (GDPR). By signing this agreement, you confirm that you are aware of this.
Privacy policy
As of May 25, 2018, the General Data Protection Regulation (GDPR) is in effect across the European Union. Gooische Practice for Speech Therapy places great importance on the protection of your personal data. For more information, please refer to our privacy policy, available on our website.
Client satisfaction survey
At the request of the health insurer, Gooische Practice for Speech Therapy conducts a client satisfaction survey after the treatment period. The purpose of this survey is to ensure the quality of treatment and the safety of the client. By signing this agreement, you give permission for the use of your email address to send a survey, which is conducted by Mediquest, an independent and certified measurement agency. We kindly ask you to complete this survey and return it within the specified time. The results are processed anonymously.
Declaration
I hereby declare:
- That, in the case of shared parental authority or guardianship, I will inform the other parent/guardian of the treatment and provide the necessary information.
- That I agree with the privacy policy as stated on the website, and that I give consent for consultation and information exchange (such as reports) with third parties, including the general practitioner, school doctor, ENT specialist, dentist, internal supervisor, school, etc. I also give permission for access to the school file for the purposes of speech therapy treatment, if applicable.
- That I consent to the sharing of information (such as reports) with third parties, if in the future information is requested regarding the treatment, for new assessments or treatments outside of Gooische Practice for Speech Therapy.
- That I agree to receive a client satisfaction survey after the treatment, with the results being processed anonymously.
I confirm that I have read and agree to the above arrangements. In the event of changes to insurance, address, or other personal details, I will promptly inform the therapist.
Date: ……………………………………………………………..................................
Name (parent of) client: ……………………………………………….....
Signature:………………………………………………………………………….....
Download the treatment agreement here (NL)
Download the treatment agreement
here (EN)
