Patient Consent Form

Step 1 of 2

CGHMC PIN Number(Required)

Please ensure you enter your correct CGHMC Permanent Identification Number. For assistance, seek help from the information desk, admissions office, or the Outpatient Department.

At CGHMC, we provide exceptional healthcare and advanced medical knowledge and practices. In line with the Data Privacy Act of 2012, we prioritize your privacy and securely manage your personal data. This form is designed to inform you about how we intend to use your personal data and your rights concerning this usage.

Purpose of Data Use:

Your personal data will be utilized to improve healthcare services, including but not limited to:

Medical Care and Treatment: To provide high-quality medical care and treatment.
Billing and Payment Processing: To manage billing, process payments, and handle financial transactions.
Compliance with Legal and Regulatory Requirements: To comply with laws, regulations, and government mandates.
Hospital Operations and Quality Improvement Initiatives: To improve hospital operations, quality initiatives, and patient care.
Conducting Medical Research and Educational Training: To conduct medical research and training programs.

Scope of Data Use:

For the abovementioned purposes, we may process personal data such as your medical history, diagnostic results, treatment information, and demographic details.

Data Controller & Protection Measures:

The Data Privacy Office at CGHMC is responsible for managing your personal data in compliance with privacy standards. We implement various protection measures, including data anonymization and restricted access, to safeguard your information.

Data Sharing and Disclosure:

Your data may be shared with:

Healthcare Providers: To coordinate your care and treatment.
Insurance Companies: To process claims and payments.
Regulatory Bodies: To comply with legal and regulatory requirements.
Courts and Legal Authorities: To respond to subpoenas, court orders, or legal processes.
Third Parties: Under strict confidentiality agreements for the purposes mentioned above.

We ensure that any third parties with whom we share your data are bound by confidentiality agreements and are required to protect your data in accordance with this Privacy Notice and applicable laws.

Data Retention:

Your data will be retained as necessary to implement the stated purposes and securely disposed of accordingly or anonymized thereafter.

Voluntary Participation & Withdrawal of Consent:

Participation is voluntary. You may withdraw your consent at any time, which will not affect the quality of your medical care. For withdrawal or inquiries, please contact our Data Protection Officer, Jamie Francis Dy, at dpo@cghmc.com.ph.

Rights of the Data Subject Under the Data Privacy Act of 2012:

As a data subject, you are entitled to several rights under the Data Privacy Act of 2012, including:

Right to be Informed: You have the right to be informed about collecting and using your personal data.
Right to Access: You can request access to your personal data that is processed by us.
Right to Object: You have the right to object to the processing of your personal data, including processing for direct marketing, automated processing, or profiling.
Right to Erasure or Blocking: You can request the erasure or blocking of your personal data under certain conditions.
Right to Rectify: You have the right to dispute inaccuracies or errors in your personal data and have it corrected.
Right to Data Portability: Where applicable, you have the right to obtain a copy of your data in an electronic format.
Right to Damages: You may claim compensation if you suffered damages due to inaccurate, incomplete, outdated, unlawfully obtained, or unauthorized use of personal data.
Right to File a Complaint: You have the right to file a complaint with the National Privacy Commission for any violation of your data privacy rights.

Notice on Photography and Videography Restrictions:

Photography and videography within CGHMC premises that capture other individuals without consent discourage respect for privacy. However, to enhance and provide further security against and preempt criminality and other nefarious activities, the hospital is installing CCTVs strategically in various common areas.

Special Provision for Incapacitated Subjects or Minors: (Required)

If the data subject cannot sign this consent form due to incapacity, an authorized representative may sign on their behalf. A parent or legal guardian must provide consent in the case of minors.

If signing on behalf of a data subject:(Required)

I confirm that I am authorized to sign on behalf of the data subject due to their incapacity or because the data subject is a minor.

What is your relationship to the data subject?(Required)

Consent:(Required)

Yes

Please indicate your consent by checking the appropriate option above:

Yes, I agree to the data privacy policy and notice outlined in this form. I consent to the use of my personal data for all purposes stated herein, in accordance with the Data Privacy Act of 2012 and CGHMC’s privacy policies.

No, I do not agree to share my data beyond what is necessary for my treatment and care. I understand that my data will only be used for treatment purposes and not shared further.

Signature(Required)