Comprehensive medical care of patients with retinoblastoma Consent concerning the financial conditions for comprehensive medical care by the Hôpital ophtalmique Jules-Gonin (HOJG - Jules-Gonin Ophthalmic Hospital)
and the CHUV (Centre Hospitalier Universitaire Vaudois – Vaud University Hospital)
of patients and children domiciled in Switzerland or from abroad and not insured
Any patient who is not covered by a recognised insurance policy (LAMal, form E112/S, notably) hereby declares by this consent to accept the conditions set out below and consequently confirms :
[*] To be able to bear the financial costs of all medical treatments, whether as an out-patient or inpatient, carried out at the HOJG and the CHUV.
[*] To have noted the fact that all the treatments must be financed with prior deposits.
[*] To make a first bank transfer for initial deposit of CHF 40’000.- to the CHUV and CHF 20’000.- to the HOJG for the services of the first three months of treatment, according to the following list.
[*] To send by email to pediatrie@fa2.ch a copy of the official notice of the bank transfer of the CHF 40’000.- to the CHUV and CHF 20'000.- to the HOJG. Upon receipt of this document and after authentification by our finance department, the date of the first consultation at HOJG will be confirmed.
Services included in the CHUV and HOJG deposits
CHUV : Initial assessment - clinical examination
CHUV : Diagnostic consultations, taking of blood samples and laboratory analyses
CHUV : Treatment for 1 to 3 courses of chemotherapy
CHUV : Follow-up consultations, taking of blood samples and laboratory analyses
CHUV : Equipment and medications for the courses of treatment of chemotherapy
HOJG : 3 operations – examinations under narcosis with intra-vitreal injections (ESN)
CHUV bank account details
BANQUE CANTONALE VAUDOISE
CH – 1003 Lausanne
Beneficiary : Centre Hospitalier Universitaire Vaudois – CHUV
Account : 328 707 0
Clearing : 767
Swiftcode : BCVLCH2LXXX
IBAN : CH65 0076 7000 E032 8707 0
Ref : Patient’s surname-forename + date of birth + country of origin
HOJG bank account details UBS SA (Swiss Bank Union)
CH – 1002 Lausanne
Beneficiary : Fondation Asile des aveugles
Account : 243-G0206683.0
Swiftcode : UBSWCHZH80A
IBAN : CH51 0024 3243 G020 6683 0
Ref : Patient’s surname-forename + date of birth + medical unit
[*] To have duly noted the fact that additional deposits will be requested in the event of additional services or an extension of the treatment.
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[*] To be aware and accept the fact that the treatment will be suspended if the additional deposits are not paid regularly.
[*] To duly note that an invoice is drawn up for each course of treatment at and/or admission to the HOJG or CHUV. This takes into account the deposits made and the tariff applicable to a patient from abroad. If the deposits do not cover the costs, an additional payment must be made. If they exceed the costs, the balance will be refunded or transferred to the HOJG in order to finance the continuation of the medical treatment.
[*] To duly note the additional elements as follow :
You must deal with organising the return trips, any necessary resident authorisations for Switzerland (visa or similar) as well as food and accommodation during the stay in Switzerland.
On request, and if there is room in a partner residence, the HOJG can organise your accommodation during the time you spend in Switzerland. However, the costs for this must be paid by you at the latest on the day when you leave the residence (roughly CHF 150 per day and per adult, including food).
If the first ESN modifies the medical diagnosis and the initially proposed treatment plan, the head doctor of the relevant unit and the social services will explain the changes to you and their financial implications.
If a significant modification is made, you could be requested to provide a new official financial guarantee (bank, State or similar).
Each appointment is conditional on the payment of a prior deposit for the treatment cost. The deposit may be made by bank transfer to the account indicated above (with the UBS bank) or by payment of the deposit on the actual day (by credit card or in cash). For security reasons, we recommend payment by bank transfer.
Consent / agreement
I, the undersigned,
Surname and forename : .....................................................................................................................................
Home address : ...................................................................................................................................................
Country : ...........................................................................
Parent and/or the person legally responsible for the child
Child’s surname and forename : ..........................................................................................................................
Child’s date of birth : .........................................................
confirm to have duly noted the aforesaid information and to accept the financial and organisational conditions relating thereto.
Thus done in Lausanne on : .............................................
Signature of the person legally responsible for the child : ...................................................................................
Copy: HOJG oncologic and paediatric unit
HOJG deposits office and invoicing service
CHUV Administrative management of CHUV patients – Admissions – BH08, 1011 Lausanne
CHUV Administrative management of CHUV patients – Invoicing – BH08, 1011 Lausanne
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