This form will provide the Private Patient team with the information necessary to charge patients for private treatment at the hospital (e.g. details of how payment will be made) and other details that will allow us to register private patients for private treatment.

Signing this form is important because it also indicates that patients (or others paying on behalf of patients) are aware that they are liable for charges relating to their private care at the hospital – even if they have insurance (for instance where insurers don’t cover all costs associated with treatment).

If the treatment is for a minor (under the age of 18) then the minor’s parent or guardian must sign the Agreement to Pay form on behalf of the minor. In so doing the minor’s parent or guardian will be agreeing to pay for any treatment on behalf of the minor, where this is not covered by private insurance, in accordance with these terms and conditions.

Further details about the role and implications of the agreement to pay form are provided on our private patients terms and conditions page.

Printable version of this page

GHNHSFT Private patients agreement to pay form V1.1 Department: Private patients PDF, 148.6 KB, 2 pages