Contract about Providing Medical Care
Name:
Surname:
Title:
Date of Birth:
Address where could be contancted
Phone Number and E-mail Address
Number of Identification Card
Nationality
(hereinafter “Patient“)
and
Institute of Clinical and Experimental Medicine
Vídeňská 1958/9
140 21 Praha 4
IN: 00023001
TIN:CZ00023001
Email:
Phone Number:
Represented by:
Function:
(hereinafter “Provider“)
are concluding Contract about Providing Medical Care (hereinafter “Deal“) Subject of this
Agreement is pledge of Provider to perform medical treatment according to their best findings
of medical science and the best dispensable instrument and equipment and Patient’s pledge to
settle payment.
I. Payment
Internal part of this Agreement is the Supplement. The Supplement contains determination
and scope of required medical care on the first place. Summary from the Pricelist of provided
care (hereinafter “Pricelist“) is following with mentioned basic medical performances that
will be charged to Patient after performance of treatment. Supposed amount is introduced at
each medical performance. Quality and price of used material and treatment means is
specified in case of need.
Estimation of whole amount is stipulated in conclusion, this comes from Pricelist and
probable course of treatment.
The whole Pricelist is for inspection at Provider whenever.
F96b IKEM - Contract about Providing Medical Care (English version)
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II. Pattern of Settlement
The patient pledges to pay advance payment in amount of 90 % from estimation of whole sum
introduced in Supplement before initiating of medical treatment ether - in cash office of
Provider at least on the iniatiation day of medical treatment or noncash transfer to IKEM
account established at ČSOB, Revoluční 11, Praha 1, account number: 126005018/0300 in a
way that advance payment would be passed to account at lest one day before initiation of
treatment.
III. Complience with Health Public Insurance
Patient does not request consciously providing of medical treatment in scope on basis of
public health insurance.Request for providing of health care out of public health insurance
was made seriously, comprehensibly and repeatedly from patient side before conclusion of
agreement. On basis of Par.11 Section 1 Subsection d) Act N. 48/1997 Coll. patient has been
instructed that in such case it is not possible to combine compensation from fund of public
health insurance.
IV. Proceedure after Conclusion of Treatment
Statement of deposit will be done by Provider promptly according to possibilities after
finishing of treatment, otherwise within 3 days after finishing and in 6 months at the latest
since signing deal. Additional charge will be paid by Patient within 15 days since conclusion
of treatment in way introduced in art.II, on cash payment additional charge is due without
delay after assumption of statement.
V. Other Agreements
Patient can withdraw from Agreement whenever before initiation of medical performance.
Provider can withdraw from Agreement before initiation of medical performance in case it
would not be able to meet the obligations to perform care performance according to the best
findings of medical science and perfect dispensable instrument equipment.
VI. Final Provisions
This agreement is result of independent and seriously meant decision of contractual sides.
Patient will receive one from three copies and Provider two.
In Prague, of the day:
Patient Signature:
In Prague, of the day:
Doctor Signature:
Stamp of IKEM Department:
F96b IKEM - Contract about Providing Medical Care (English version)
version 01
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