Travel Medicine Questionnaire

The travel medicine consultation is charged according to GOÄ (fee schedule for doctors) and is composed as follows:

1. the travel medicine consultation: €67.01
2. the issuing of a prescription for the vaccines: €3.15 per prescription
3. the vaccination of the vaccine: €10.72 per vaccination
   the 2nd vaccination in the same session: €6.70
4. additional costs for the vaccines (to be paid directly by you at the pharmacy)

The timeline and the necessary steps are described on our website under “Services / Travel Medicine”.

The services described are considered agreed and the costs are to be paid by you, regardless of whether your insurance reimburses them. You confirm this with your signature at the end of this form.

Invoice Assignment

We work with our partner AvisCode GmbH for invoicing and billing.
If you have any questions about billing, please contact us: rechnung@avismed.de

Your data will only be passed on on the basis of your consent and in compliance with the GDPR and the medical confidentiality obligation in accordance with § 203 StGB, which also applies to all AvisCode employees.

Thank you for your trust
Your Avismed Team

Please read the Information on data protection according to Art. 13 and 14 GDPR.

I agree with the

• Disclosure of the personal data required for billing and enforcement of the fee claims (e.g. name, date of birth, address, treatment and examination data) to AvisCode GmbH. I am informed that AvisCode uses external technical service providers to process this data, who act exclusively on behalf of AvisCode GmbH and are contractually obliged to comply with the applicable data protection regulations in accordance with Art. 28 GDPR
• Commissioning AvisCode by my doctor to create, send and manage invoices and payment reminders in my name, including the use of an online portal to provide this information
• Disclosure of the information from the patient file required to justify the invoice to AvisCode and – in the event of a dispute – to courts or legal advisors. I release my doctor and the employees of AvisCode from the obligation of confidentiality to that extent
• the release of Avismed from the obligation of confidentiality towards the external partner should there be different opinions in the course of the claim

I am informed that my treatment is not dependent on consent to the processing operations described above. This consent also applies to claims from future treatments. This declaration is made voluntarily.
The consent can be revoked at any time with effect for the future. The revocation does not affect the legality of the processing carried out up to that point on the basis of this consent.
If the declaration is submitted as a legal guardian of a minor child, I assure that the other legal guardian also agrees to the above regulations.