Provider Name: (Full Trading Name) ______
Contact Person: ______
Practice Number: ______
Postal Address: ______
Physical Address: ______
Provider contact’s Tel no: / Code ( ) / Tel No: ______
Provider contact’s Fax no: / Code ( ) / Fax No: ______
Provider E-mail Address: ______
TERMS AND CONDITIONS FOR REMITTANCE ADVICE DATA
- By signing this document you provide your consent that the Medical Scheme/Pharmaceutical Benefit Management Company is authorized to supply BI Solutions with remittance advice data pertaining to your practice as per the BHF number specified in this form and all data that we receive is treated as confidential and is only passed onto the relevant practice.
- Please note that BI Solutions shall make all reasonable efforts to ensure that the remittance advice data given by the Medical Scheme/Pharmaceutical Benefit Management Company is accurate.
- BI Solutions shall however, not be liable whether in contract, delict or otherwise, for any direct, indirect, special or consequential loss or damage or any loss of profit suffered or sustained by your practice as a result of or on connection with the use of or reliance on incorrect data provided by Medical Scheme/Pharmaceutical Benefit Management Company or your omission to inform us of any change of your provider details.
- BI Solutions is responsible for the download of remittance advice files into the relevant mailboxes for access by your practice.
- Should the remittance advice file be inaccessible, or not available, kindly contact BI Solutions in this regard.
- Should the down load of the file not be successful i.e. the integration of the file into Practice/Pharmacy/ Hospital management software be unsuccessful, you must contact your vendor for assistance in respect thereof.
- In the event that your practice terminates with BI Solutions, it remains the responsibility of the practice to notify the Medical Scheme/Pharmaceutical Benefit Companies.
- Please also note that by affixing your signature hereto, you confirm your acceptance of the above terms and conditions.
SIGNED AT ON THIS DAY OF ______20
Signature: Provider Owner/ManagerName of signatory
Who by his/her signature hereto warrants that he/she is duly authorized to bind the Provider.
Signature: BI SolutionsName of signatory
Who by his/her signature hereto warrants the he/she is duly authorized to bind BI Solutions.