With my signature I authorize the doctor to send the fee invoice electronically to the health insurance company. For health insurance companies that do not support this system (e.g. Agilia, Agrisano, Assura, Cigna, Galenos, EasySana, Innova, Sanagate, Swisscare), the invoice will be sent directly to your home address. Contact our practice staff if you want copy to home address for your receipt.
I give permission to forward the data required for invoicing both to the invoicing party and to the institution responsible for any collection or the lawyer involved, as well as the responsible state authorities. My doctor is authorized to request medical files about me for inspection and to forward them in my interest.
Choice of law: For the legal relationship between the parties, and in particular for all claims related to examinations, treatments and any other services (performed by the Aeschenpraxis in the office, or at Bethesda-Spital, or at Merian-Iselin-Klinik, Swiss substantive law, namely the Swiss Code of Obligations, is applicable.
Place of jurisdiction: The sole place of jurisdiction for all disputes in connection with this agreement is Basel, Switzerland. Aeschenpraxis at the office, or at Bethesda-Spital, or at Merian-Iselin-Klinik, is entitled, at her own discretion, to place the matter before the ordinary courts at the patient’s domicile.
The patient declares with sending this form, that she has truthfully given the above information.
If you are unable to attend this appointment, please call us at least 24 hours before the appointment to arrange a new appointment with you. If the appointment is not cancelled in time, we reserve the right to charge for the missed treatment.