APPROVED
by the decision of the Board of
the LLC “RIGA EAST UNIVERSITY HOSPITAL”
No.V1/01-01/14/23 dated 16 January 2014
LLC “RIGA EAST UNIVERSITY HOSPITAL”
medical treatment contract with the patient on chargeable services in the in-patient department / day in-patient
department
Riga, ___ __________ 201__
LLC “RIGA EAST UNIVERSITY HOSPITAL”, reg. No.40003951628, registered address: Hipokrāta iela 2, Riga, LV-1038, phone: 67042400,
fax: 67024786, hereinafter referred to as the “Hospital”, which is a medical treatment institution compliant with the requirements of laws and
regulations
of
the
Republic
of
Latvia,
which
is
represented
by
the
authorized
person
thereof
____________________________________________________________________________________________ acting on the basis of a power of
attorney in compliance with the decision of the Board of the Hospital No.V1/01-01/12/577 dated 13 December 2012, on the one hand, and the patient
/ or authorized person thereof
first name, last name
personal code
–
Passport / ID card No.
address
place of work ___________________________________________________________________________________________.
hereinafter referred to as the “Patient”, on the other hand, both of them jointly and each separately hereinafter referred to as the “Parties”, enter into
the following contract, hereinafter referred to as the “Contract”:
1. Subject-matter of the Contract
1.1. The Patient assigns and orders and the Hospital undertakes to provide medical services to the Patient in the in-patient departments / day inpatient departments of the Hospital in compliance with the provisions of the Contract.
1.2. If the Patient has the right to receive a planned health care service, by signing the Contract the Patient certifies that he or she refuses
from waiting for such a service, and the Patient himself or herself or a third person undertakes to make all the payments for the
received chargeable health care services.
1.3. The Patient pays for medical services provided by the Hospital within the framework of the Contract according to the procedure specified in
paragraph 4 of the Contract and in compliance with the “Price-list for chargeable services” of the LLC “RIGA EAST UNIVERSITY HOSPITAL”
(hereinafter referred to as the “Price-list for chargeable services”).
2. Procedure for providing services
2.1. Within the framework of the Contract, the Hospital provides medical services to the Patient through the intermediary of the employees thereof –
certified doctors and other medical practitioners.
2.2. The Hospital has the right to choose Patient’s attending doctor and other medical practitioners, if the Patient has not particularly specified his or
her choice.
2.3. If Patient’s life or health is threatened, the Hospital shall be entitled to provide medical services to the Patient, without taking into account the
wish expressed by the Patient regarding medical practitioners.
2.4. The Patient, while receiving medical services and staying within the territory owned by the Hospital, is obliged to comply with internal regulations
of the Hospital, directions of doctors and other medical practitioners.
3. Certifications
3.1. By signing the Contract, the Patient certifies that he or she has been fully explained and he or she fully understands, is aware and accepts
possible risks and consequences which may occur during or as a result of provision of medical services. The Patient undertakes not to pursue
unjustified claims against the Hospital. If the Patient pursues a claim against the Hospital in the court, but this claim has been rejected and the
judgement has entered into lawful force, the Patient shall be obliged to repay to the Hospital all direct and indirect losses incurred as a result of
it.
3.2. By entering into the Contract, the Patient authorizes the Hospital to take all necessary actions and apply medical technologies selected by the
Hospital, in order to achieve the result of medical services which is the most effective and favourable for Patient’s health.
3.3. By entering into the Contract, the Hospital undertakes responsibility for the conformity of medical services provided to the Patient to the medical
standards accepted in the Republic of Latvia and generally accepted medical practice.
3.4. If Patient’s insurer undertakes to pay for medical services in compliance with the provisions of the relevant health insurance policy and contracts
concluded by the Hospital, and upon entering into the contract the Patient has shown the original of the insurance policy or insurance card
which guarantees payment for the received service, then by signing this Contract the patient shall consent to that the Hospital, in compliance
with the request of the relevant insurance company, provides to this company the information regarding the insured Patient, his or her health
state and received medical aid, which is required for establishing the circumstances of the insured event.
3.5. By signing the Contract, the Patient certifies that he or she has been informed and does not object that his or her personal data, data about his
or her health state, as well as data about the treatment are processed and used for record-keeping of Hospital’s work, and persons involved in
education and research work may use these data for scientific analytical work or medical educational work at the Hospital, complying with the
requirements of the “Personal Data Protection Law” and “Law on Patients’ Rights” of the Republic of Latvia.
Autentisks veidlapas tulkojums no latviešu valodas.
This is an authentic translation from the Latvian language
4. Contract price and payment procedure
4.1. The Parties agree that the Patient shall pay for medical services provided by the Hospital within the framework of the Contract according to the
account issued by the Statistical Division of the Hospital for the provided medical services, the payment shall be calculated in compliance with
the “Price-list for chargeable services” of the Hospital and internal regulatory enactments of the Hospital.
4.2. The Patient settles the account with the Hospital for the provided medical services on the day of discharge from the Hospital in cash by paying
the relevant cash amount at Hospital’s cash-desk for patients’ payments. If the Patient, having received a health care service, is unable to make
patient’s payment, it can be done within 15 (fifteen) days following the receipt of the health care service or within another term, if a written
agreement with the Hospital has been achieved.
4.3. Payments by transfer according to the account issued by the Hospital shall be made to the following account, obligatory specifying the following
information in the purpose of the payment: patient’s first name, last name, personal code, number of the medical record, invoice number:
LLC “RIGA EAST UNIVERSITY HOSPITAL”
Reg. No.40003951628
Account: LV24HABA0001407045805
Bank: Swedbank, HABALV22.
4.4. The Patient has the right not to pay for medical services which Patient’s insurer has undertaken to pay for in compliance with the provisions of
the relevant health insurance policy and contracts entered by and between the Hospital and insurance companies, if upon entering into the
Contract the Patient has shown the original of the relevant policy. If the amount specified in the account to be paid for services exceeds the limit
specified in the health insurance policy or the amount specified in the guarantee letter issued by the payer, this difference shall be borne by the
Patient.
4.5. The Hospital has the right to transfer the recovery of the amount of delayed payments to third persons. Expenses related to the recovery of
amounts of delayed payments are borne by the Patient.
4.6. If Patient’s insurer does not pay for the services provided by the Hospital in compliance with the provisions of the relevant health insurance
policy and the patient has not paid for these services, the Hospital shall have the right to apply with the recovery of the payment for medical
services against the Patient, either directly or with the help of third persons.
5. Rights and obligations of the Parties
5.1. Within the validity term of the Contract, the Patient:
5.1.1.
upon registration at the Hospital, is obliged to show a personal identification document with records specifying personal code and state
affiliation, and the original of a valid health insurance policy (if any). If the Patient is represented by an authorized person, personal
identification document of the lawful representative has to be shown;
5.1.2.
is obliged to provide to the Hospital the information about his or her health state, changes in it, symptoms, as well as nuances of previous
treatment immediately upon request;
5.1.3.
is obliged to comply with the directions given by doctors and other medical practitioners;
5.1.4.
is obliged to comply with Hospital’s regime, internal regulations, fire safety requirements and generally accepted rules of comity;
5.1.5.
is entitled to refuse from receiving all or particular medical services, notifying the Hospital of it in writing;
5.1.6.
is entitled to refuse from discussion of his or her health state during the class of medical students, notifying his or her attending doctor of it
in advance;
5.1.7.
is entitled to ask not to provide information to his or her relatives about the information present in patient’s medical documentation, notifying
his or her attending doctor in writing in advance;
5.1.8.
is obliged to pay for the received chargeable medical services in compliance with the provisions of the Contract and “Price-list for
chargeable services” of the Hospital;
5.1.9.
is entitled to request from the Hospital for the full information regarding his or her health state, diagnoses and forecasts, and to receive from
the Hospital an extract with recommendations in the official language on the day of discharge. The Hospital, within its compass, provides
copies of extracts, statements and other documents, and the translations thereof in other languages to the Patient at a charge in
compliance with the prices specified in the “Price-list for chargeable services” of the Hospital.
5.1.10. is obliged to indemnify to the Hospital all the losses caused by him or her within the framework of the Contract;
5.1.1.
upon discharge from the Hospital, is obliged to take Patient’s belongings from Hospital’s warehouse (safe) with a delivery and acceptance
act (clothes, shoes, valuables, documents, etc.);
5.1.2.
is obliged to leave Hospital’s ward by 12:00 on the day of discharge, if an extract has been received.
5.2. Within the validity term of the Contract, the Hospital:
5.2.1.
is obliged to recommend and provide medical services the most suitable for improving Patient’s health state, taking into account written
Patient’s refusal in compliance with paragraph 5.1.5 of the Contract, if such is received;
5.2.2.
is entitled to refuse from providing medical services to the Patient, if the Patient does not fulfil the obligations undertaken pursuant to this
Contract, except for the cases, when such refusal in the relevant situation is directly prohibited by regulatory enactments of the Republic of
Latvia;
5.2.3.
is obliged to document the progress of Patient’s treatment in the medical record, as it is specified in regulatory enactments of the Republic
of Latvia;
5.2.4.
is obliged, within its compass, to ensure maximum short and convenient treatment process for the Patient, without affecting the quality of
the provided service;
5.2.5.
the Hospital is responsible for the harm caused to Patient’s health in compliance with regulatory enactments of the Republic of Latvia;
5.2.6.
is obliged to comply with confidentiality principles in relation to Patient’s health state according to laws and regulations.
5.3. During the validity term of the Contract, the Patient is not entitled to take any actions that might harm patient’s health (to use alcohol, to smoke,
etc.). The Hospital shall not be responsible for the harm caused to Patient’s health, if the Patient has not complied with the provisions of this
Contract or directions of medical practitioners.
5.4. Within the framework of the Contract, the Hospital does not undertake responsibility for personal belongings of the patient and does
not undertake to pay indemnification of losses.
Autentisks veidlapas tulkojums no latviešu valodas.
This is an authentic translation from the Latvian language
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6. Final provisions
6.1. The Contract comes into effect upon the signing thereof and is valid till the moment when the Parties will have fulfilled all the liabilities
undertaken pursuant to this Contract.
6.2. Any additional agreements related to the provision of medical services at the Hospital shall become an annex to this Contract and an inherent
part thereof upon signing by both of the Parties.
6.3. All disputes related to this Contract shall be resolved via mutual negotiations. If the Parties fail to agree, the dispute shall be resolved according
to the procedure specified in laws and regulations of the Republic of Latvia.
6.4. The Contract is drawn up in Latvian in two identical copies with equal legal force. Each party has one copy of the Contract.
Hospital’s authorized person:
Patient / authorized representative:
____________________
_________________________
Autentisks veidlapas tulkojums no latviešu valodas.
This is an authentic translation from the Latvian language
3