Privacy statement Healthcare performance model (ggz)
The undersigned, client and healthcare provider,
to declare:
- That a treatment relationship has been entered into between them in the context of mental health care, for which the healthcare provider wishes to charge a rate in accordance with the Healthcare Market Regulation Act.
Mention in declaration - That the client, from the point of view of protecting his privacy, objects to data that can be traced back to a diagnosis and/or care demand characterization made by the healthcare provider with regard to the client being included in the declaration.
- That the healthcare provider, in accordance with Article 4.3 of the Mental Healthcare and Forensic Care Regulations, will omit the information stated under 2.
Delivery to NZa - That the client, from the point of view of protecting his privacy, objects to data that can be traced back to a diagnosis and/or care demand characterization made by the healthcare provider with regard to the client, being supplied to the NZa.
- That the healthcare provider, in accordance with Article 4.3 of the Mental Healthcare and Forensic Care Regulations, will refrain from supplying the data referred to under 4 to the NZa.
This statement applies if the client has signed the Registration Agreement and has entered YES under “Agree to Privacy Statement”; or by signing below:
PLACE………………………………. DATE: …………………………………………
Client name: …………………………………………. Date of birth: ………………………………
Client’s signature: Practitioner’s initials: ………………
