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.

PRIVACY NOTICE FOR PATIENTS, RELATIVES, AND/OR WATCHERS

The Chinese General Hospital and Medical Center (CGHMC), under the Philippine-Chinese Charitable Association, Inc. (PCCAI), strictly complies with the Data Privacy Act of 2012 (RA 10173) to protect your personal and medical information.

PERSONAL INFORMATION WE COLLECT

General & Medical Data: We collect personal details, medical history, diagnostic results, and billing information during admission, consultations, and via CCTV monitoring.
Minors & Incapacitated Patients: Information and consent are collected exclusively from parents, legal guardians, or authorized representatives.

PURPOSE AND LEGAL BASIS

We process your data primarily to provide medical diagnosis and treatment, process billing and PhilHealth/insurance claims, and manage hospital safety.
This processing is legally based on your consent, fulfillment of medical contracts, protection of life and health, and compliance with DOH and legal obligations.

THE MERX CONSENT INDICATOR SYSTEM

To safeguard your data, CGHMC utilizes the MERX system:

RED (Default): Your data is used for direct medical treatment only.
GREEN: You have provided specific consent for your data to be used for medical research, training, and teaching. You may update this status at the Data Privacy Office at any time.

DATA SHARING AND SECURITY

Your data is secured through anonymization, restricted biometric access, and secure storage systems.
We only share your information on a need-to-know basis with your healthcare team, insurance providers, and legally mandated government agencies (e.g., DOH, BIR, PNP).

RETENTION AND DISPOSAL

Patient records are retained strictly in accordance with DOH Administrative Orders and CGHMC’s internal Data Retention Policy.
Upon expiration of the retention period, records are securely destroyed via the Centralized Documents Disposal Warehouse.

YOUR RIGHTS AND COMPREHENSIVE GUIDELINES

Under the DPA, you have the right to be informed, to access, and to object to the processing of your data.

For comprehensive guidelines on our CCTV policy, please scan the QR code below.

For inquiries or to exercise your rights, contact our Data Protection Officer or Compliance Officer – Data Privacy.

DR. ANDRE DANIEL E. VILLANUEVA
Director – Business Development and Quality Management
Data Protection Officer (DPO)

ENGR. ALFONSO JONATHAN PAÑGAN III, ECT, CDPO
Compliance Officer – Data Privacy (COP)

E-mail Address: dpo@cghmc.com.ph
Website: https://dpo.cghmc.com.ph

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)

GENERAL CONSENT FOR TREATMENT-RELATED PROCESSING

I acknowledge that I have read and understood the CGHMC Privacy Notice via the QR code below. In accordance with the Data Privacy Act of 2012, I am indicating my decision below regarding whether to freely give my specific and informed consent to CGHMC and its authorized healthcare professionals to collect, use, and process my personal and sensitive personal information (including medical records, imaging, and billing data) strictly for my medical diagnosis, treatment, continuity of care, and standard administrative functions (such as admission, billing, PhilHealth claims processing, and medical records management). Furthermore, I understand that by choosing 'I Consent' below, I also authorize the sharing of my information/data with healthcare providers, medical trainees, insurance companies, regulatory bodies, courts, and other reportorial processes/subpoenas/orders and third parties under strict confidentiality agreements for the abovementioned purposes.

I Consent

I Do Not Consent

In addition to direct medical treatment, CGHMC conducts public health initiatives and medical education. You have the right to choose whether your anonymized and de-identified medical data may be used for these secondary purposes. Your choice here will not affect the quality of your medical treatment.

Consent:(Required)

OPTION A – GREEN CONSENT (Authorized)

OPTION B – RED CONSENT (Treatment Only)

Please indicate your consent by checking the appropriate option above:

I consent to the use of my anonymized medical data for clinical research, case studies, and healthcare training.

I do not consent to the use of my data for research or training. My data shall be used solely for my direct medical treatment.

Signature(Required)

I understand my rights under the Data Privacy Act, including the right to withdraw this consent at any time by contacting the CGHMC Data Privacy Office.