Declaration of consent

Private medical billing Video consultation

1. I agree to the forwarding of the information required for the purpose of billing for the medical services provided, in particular information taken from the patient file (name, date of birth, address, diagnosis, examination and treatment data) and the assignment of the claim for the purpose of collection to the Mosel-Saar Private Medical Clearing Office (PVS Mosel-Saar for short), Metternichstraße 29a, 54292 Trier and Boxbergweg 3a, 66538 Neunkirchen.

2. I agree that PVS Mosel-Saar will invoice my doctor’s services in its own name and collect them for its own account. Should there be any differences of opinion regarding the justification of the claim, I agree to the forwarding of the additional data from the patient file required to justify the invoice. In the event of any legal dispute, PVS Mosel-Saar is a party to the proceedings; my doctor may be heard as a witness. In this respect, I hereby also release my doctor from his duty of medical confidentiality.

3. this declaration also applies to claims arising from future treatments. It can be revoked at any time in writing to my doctor or PVS Mosel-Saar with effect for the future. The withdrawal of consent shall not affect the lawfulness of processing based on consent before its withdrawal. In the event of revocation, no further data transfer will take place between my doctor and PVS Mosel-Saar.

 

Information in accordance with Art. 12 ff GDPR in conjunction with §§ 32 ff BDSG

PVS Mosel-Saar is subject to the provisions of statutory confidentiality and data protection as a professional secrecy holder in accordance with § 203 StGB, as are we ourselves. If you have any questions about an invoice, PVS Mosel-Saar will be happy to help you, answer your questions about billing codes, prepare duplicate copies and support you in your arguments if there are complaints from your payer or insurance company. You can contact the PVS Mosel-Saar at the following addresses for all billing questions:

• Metternichstraße 29a, 54292 Trier or by telephone on 0651 97802 – 0
• Boxbergweg 3a, 66538 Neunkirchen or by telephone on 06821 9191 – 3
• via the Internet at www.pvs-mosel-saar.de/patienten-service/

The health data processed by PVS Mosel-Saar will be blocked as soon as it is no longer required and deleted after the statutory retention periods have expired. You have the right to obtain information about the personal data concerning you. You can also request the correction of incorrect data. In addition, under certain conditions, you have the right to erasure of data, the right to restriction of data processing and the right to data portability. Please address your data protection concerns directly to the PVS Mosel-Saar data protection officer (e.g. by e-mail to datenschutz@pvs-mosel-saar.de).

Further information on data protection at PVS Mosel-Saar can be found at www.pvs-mosel-saar.de/datenschutz/datenschutz-fuer-patienten/

You also have the right to lodge a complaint with the competent data protection supervisory authority if you believe that your personal data is being processed unlawfully. The contact details of the responsible supervisory authority in Rhineland-Palatinate are as follows:

The State Commissioner for Data Protection and Freedom of Information Rhineland-Palatinate
Hintere Bleiche 34
55116 Mainz
E-mail: poststelle@datenschutz.rlp.de