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{\title Muster f\'fcr eine Patienten-Erkl\'e4rung inkl}{\author Internet}{\operator Internet}{\creatim\yr2002\mo1\dy24\hr16\min11}{\revtim\yr2002\mo1\dy24\hr16\min11}{\version2}{\edmins0}{\nofpages1}{\nofwords0}{\nofchars0}{\*\company \'c4KB}
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{\f1\fs20 Anhang zum 
\par 
\par }{\b\f1\fs20 Wegweiser }{\f1\fs20 f\'fcr gesetzlich krankenversicherte Patientinnen und Patienten}{\b\f1\fs20 
\par }{\f1\fs20 Die private Inanspruchnahme individueller Gesundheitsleistungen (IGEL-Leistungen)
\par 
\par www.aerztekammer-berlin.de
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}
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\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \s15\qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs24\lang1031\langfe1031\cgrid\langnp1031\langfenp1031 {\f1\fs28 Muster f\'fcr eine Patienten-Erkl\'e4rung inkl.
\par der erforderlichen Honorarvereinbarung
\par }\pard \s15\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\f1\fs28 
\par }{\f1 
\par Name und Vorname der Patientin/des Patienten,\line Anschrift 
\par 
\par {\pict{\*\picprop\shplid1025{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
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00001302f401e803050000001402f40100000500000013020000e803030000000000}
\par }{\f1 {\pict{\*\picprop\shplid1026{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
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00001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 
\par }{\f1 {\pict{\*\picprop\shplid1027{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
\picw1764\pich882\picwgoal1000\pichgoal500\wmetafile8\bliptag907321276\blipupi1439{\*\blipuid 36149fbcc681ce015720994253f9dec0}010009000003310000000000070000000000050000000b0200000000050000000c02f401e803070000001b04f401e80300000000050000001402000000000500
00001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 
\par 
\par Ich w\'fcnsche, durch die/den behandelnde(n) \'c4rztin/Arzt die folgenden Leistungen gem\'e4\'df GO\'c4 in Anspruch zu nehmen:
\par 
\par Angabe der Einzelleistungen nach GO\'c4-Ziffern,\line Euro-Betr\'e4ge 
\par }{\f1\fs20 
\par }{\f1 {\pict{\*\picprop\shplid1028{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
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00001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 {\pict{\*\picprop\shplid1029{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}
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010009000003310000000000070000000000050000000b0200000000050000000c02f401e803070000001b04f401e8030000000005000000140200000000050000001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 
{\pict{\*\picprop\shplid1030{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
\picw1764\pich882\picwgoal1000\pichgoal500\wmetafile8\bliptag907321276\blipupi1439{\*\blipuid 36149fbcc681ce015720994253f9dec0}010009000003310000000000070000000000050000000b0200000000050000000c02f401e803070000001b04f401e80300000000050000001402000000000500
00001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 
\par 
\par Ich vereinbare hierf\'fcr ein Honorar \'fcber voraussichtlich Euro
\par }{\f1 {\pict{\*\picprop\shplid1031{\sp{\sn shapeType}{\sv 1}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn fillColor}{\sv 8421504}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn alignHR}{\sv 1}}{\sp{\sn dxHeightHR}{\sv 10}}
{\sp{\sn dxWidthHR}{\sv 9354}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fStandardHR}{\sv 1}}{\sp{\sn fHorizRule}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}}\picscalex935\picscaley2\piccropl0\piccropr0\piccropt0\piccropb0
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00001302f401e803050000001402f40100000500000013020000e803030000000000}}{\f1 
\par 
\par Es ist mir bekannt, dass die Krankenkasse, bei der ich versichert bin, eine im Sinne des Gesetzes ausreichende Behandlung gew\'e4hrt und vertraglich sichergestellt hat. Ich w\'fcnsche dennoch die oben aufgef\'fchrten Leistungen.
\par 
\par Ich wei\'df, dass die Behandlung nicht erstattungsf\'e4hig ist und dass der oben genannte Betrag von mir selbst zu tragen ist.
\par 
\par 
\par }\pard \s15\ql \li0\ri0\widctlpar\tx4820\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\f1 Datum:\tab Datum:
\par 
\par Ort:\tab Ort:
\par 
\par 
\par 
\par 
\par 
\par _______________\tab _______________
\par Unterschrift\tab Unterschrift
\par \'c4rztin/Arzt\tab Patientin/Patient
\par }}