Agreement between

The CENTRE FOR DIABETES AND ENDOCRINOLOGY

(Registration Number: 1994/001693/07)

( hereinafter referred to as ‘CDE’ )

and

Mr. / Mrs. / Ms. ______

Practice Number: ______

ID. NO: ______

(hereinafter known as the “dietitian”)

I, the aforementioned and undersigned hereby apply to participate as a contracted provider to the CDE Network and accept the terms, conditions and provisions as set out in this agreement.

1. Recordal:

1.1Whereas, the undersigned is a registered dietitian and member of ADSA, the Association for Dietetics in South Africa; and

1.2Whereas, ADSA has signed an agreement with the CDE, by virtue of which its members may contract with the CDE under certain conditions;

1.3ADSA hereby invites its member dietitians to take part in the contract between ADSA and the Centre for Diabetes and Endocrinology, to service certain patients with Diabetes Mellitus, under the provisions of this agreement.

1.4This agreement is only in place, and only covers diabetes related services provided to CDE patients who are members of the new reimbursement model introduced by the CDE. This agreement does not apply when a dietitan consults a patient who is a member of the fully capitated CDE reimbursement model.

2. Application and Undertaking:

2.1 The dieitian hereby formally applies for the said participation as follows:

2.2The dieitian undertakes the following:

2.2.1To successfully complete the online course in basic diabetic

management, as provided by the CDE, within 6 months of his/her signature of this agreement.

2.2.2 That he/she will perform the various services, both clinical and administrative that are contained in this agreement.

2.2.3 That the dieitian will not balance bill patients who see him/her under the provisions of this agreement, nor claim from the patient’s medical aid.

2.2.4 Claims for consultations unrelated to Diabetes Mellitus, are to be rendered to the patient’s Medical Scheme, in the usual way.

2.2.5 Only patients with Diabetes who are registered in writing on the new CDE programme, by their scheme or option, are to be seen under the provisions of the annexures to this agreement.

3. Termination:

3.1 Both the dieitian, (undersigned) and the CDE may terminate this agreement at any time, with 90 (ninety) days written notice, failing which this agreement will continue in force.

3.2.1 It is noted that from time to time changes may become necessary that affect this agreement, inter alia, but not confined to, the annual setting of fees as agreed by ADSA and the CDE, and that all participating dietitians will be informed by the CDE, of any such changes, as well as the deadline, by which the CDE, must receive the Notice of Termination, pursuant to such changes, failing which the dietitan will be deemed to have elected to continue with this Agreement.

4. Domicilium Citandi et Executandi and Contact Details:

The Participating Dietitan:

Physical:______Postal: ______

______

______

______Code: ______

Tel: ______Fax: ______

E-mail: ______

Signed by the participating dietitan at ______on this the

______day of ______2010

______

Dietitan Signature

Signed on behalf of the CDE on the ______day of ______2010

______

Duly Authorized

ANNEXURE A

PATIENT CONSULTATIONS

  1. Patients registered with the programme are entitled to at least 1 consultation per year for Diabetes dietetic management; however each patient shall have a specific, personalised treatment plan which will in fact indicate the number of dietitian consultations allowed per annum.
  1. During the “First Consultation”;

which means the first consultation between the Dietitian and the Patient, subsequent to the Patient joining the Programme, the Dietitian shall perform the following:

2.124 hour dietary recall

2.2food frequency questionnaire

2.3Medical and family history

2.4Relevant Anthropometry

2.5Basic diabetes nutritional guidelines

2.6Written suggested dietary changes to be made

2.7Nutrition education regarding relevant diabetic dietary changes needed, portion control and exercise

  1. During the “Subsequent Consultation”;

which means any consultation subsequent to the first consultation between the Dietitian and the Patient, whilst the Patient is a member of the Programme, the Dietitian shall perform the following:

3.124 hour dietary recall

3.2Relevant anthropometry

3.3Reinforcement of diabetes guidelines and dietary changes

4. Additional consultations for diabetes management shall not be claimed from the CDE, unless a motivation for such additional consultations has been made, and authorisation is given for such additional services. Such motivations may be sent to:

CDE case management

Fax: 011 728 6661

Email:

5. The CDE diabetes programme shall provide a definitive response to such motivations for additional services, within 7 days of request.

ANNEXURE B

REIMBURSEMENT RATES AND TARIFFS

FOR

DIETITIANS

Participating Dietitians shall be entitled to claim reimbursement for consultation services rendered, directly from CDE, with the following conditions:

1) Dietitians may only claim for consultation services that are in accordance with patient specific treatment plans.

2) Neither balance billing of Patients nor balance billing of Medical Aid Schemes shall be allowed.

3) Dietitians must claim directly from CDE, via one of the switches on claiming code CDE710;

4) Dietitians must include at least the following information when claims are made to CDE:

i) Name of the Patient

ii) CDE membership number

iii) ICD10 code specific to diabetes (E10 or E11)

iv) Tariff code : 84206

v) Date of service

5) Dietitians shall be reimbursed for tariff code 84206 only, at the rate of R 360 per approved consultation (2010 rates, including VAT)

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