TO THE PATIENT/REQUESTOR: YOU HAVE THE RIGHT TO BE INFORMED ABOUT YOUR PERSONAL DATA WHICH WILL BE ENTERED INTO OUR SYSTEM AND THE PURPOSE(S) FOR WHICH THEY WILL BE PROCESSED. KINDLY READ ALL THE INFORMATION ON THIS FORM BEFORE ACCOMPLISHING AND SIGNING IT. IF YOU HAVE QUESTION(S) OR CONCERN(S), PLEASE FEEL FREE TO ASK ANY OF OUR STAFF. TAWAGIN ANG PANSIN NG EMPLEYADO NG MAKATI MEDICAL CENTER O TUMAWAG SA +632 8888 8999 KUNG HINDI NAKAKAUNAWA NG INGLES.
I. Consent for Information Registration and Other Data Processing:
1. I certify that the information above are true and correct.
2. In the course of my treatment or availment of other healthcare services, I consent to the
processing (collection, recording, retrieval, use, retention, and disposal/destruction) of
my personal data, as provided under applicable laws, regulations, and the Hospital’s
policies and guidelines. Such personal data are those relevant to the purpose of my
diagnosis, treatment, availment of healthcare services, diagnostic results and radiologic
images accessed online (when available), text messages received (via SMS or Viber)
regarding my appointment, relevant health education, and transmit medication
prescription from my physician or his/her designate to me or my legal representative/
family, and process of hospital bills, claims, and quality improvement activities for
enhancement of patient care.
3. I consent to making my information available to healthcare team members who are involved in the management of my care, including the hospital’s service providers and partners, and to other applicable parties such as regulatory authorities, such as the Department of Health, PhilHealth, my employer, my Health Maintenance Organization (HMO), and/or insurance provider for the payment of my hospital bills.
4. I am aware that the hospital is equipped with CCTV cameras to ensure the safety and security of the patients, the employees, and the establishment. I am informed that a CCTV camera is located in each patient’s room in the Neuropsychiatric unit and COVID units to monitor in real time and record medically significant developments or behavior. However, no video recording of such will be made and kept on file.
5. I am aware of my rights in relation to the Personal Data that may be collected from me and my next of kin/legal representative, including right to access, correction, and to object to the processing of the same. I may visit https://www.privacy.gov.ph/know-your-rights for more details of my rights on data privacy.
6. I am aware that I may direct my complaints or questions to the hospital's Patient Relations Department through Patient.Relations@makatimed.net.ph, https://www.makatimed.net.ph, or by calling (+632) 88888 999 local 3034. If my concerns are not acted upon, I may consult Makati Medical Center’s Data Protection Officer at dataprivacy@makatimed.net.ph.
In case the hospital is unable to address my concerns, I have the right to lodge a complaint before the National Privacy Commission at https://privacy.gov.ph for any privacy concern regarding my personal data.
II. Consent for Admission and Procedure(s):
7. I grant authority to Makati Medical Center (MMC) and its staff to perform urgent
procedure(s) and treatment(s) necessary for my safety and well-being.
8. I agree that all drug(s)/ medicine(s) required and administered to me are secured, purchased and dispensed only from MMC’s pharmacy. The undersigned further waives any option to purchase drug(s)/ medicine(s) outside of the hospital’s pharmacy.
9. I am aware that certain drugs or agents without approval by the Philippine Food and Drug Administration (FDA) may be used during my stay – subject to my approval after such has been explained.
10. MMC has implemented stringent infection prevention and control protocols in its processes and among its healthcare workers. To limit the risk of exposure to any communicable disease, having visitors is strongly discouraged. Likewise, I am aware of the risk of exposure to a communicable disease to or from any companion.
11. I and my immediate family (and/or legal representative) are aware that we will receive education regarding any procedure/treatment to be performed in Makati Medical Center. All my questions and concerns will be addressed to my satisfaction before a procedure/treatment will be done.
12. I am aware and I understand that there is a difference in the pricing of diagnostic procedures for inpatient and outpatient services. Inpatient rates may be higher than outpatient services due to administrative and operational expenses relating to the care management of inpatients.
13. I and my immediate family (and/or legal representative) are aware that the price lists of relevant treatment, medical or surgical procedures or services will be presented and explained to us upon admission or before the performance of a procedure/treatment. I agree, with my immediate family to discuss directly with my Attending Physician(s) the professional fees for the procedure or treatment before it is performed. Price estimates can be requested from the nurses’ station. While admitted, I can access my running hospital bill online through the Makati Medical Center’s website. Details of the bill can be discussed with the assigned Billing Officer.
14.I authorize Makati Medical Center and its staff to perform necessary procedure(s) and treatment(s). If, during the procedure/treatment, other condition(s) are discovered, and in the best judgement of my physician or surgeon, require an extension of the original contemplated procedure or require additional procedure(s)/treatment(s) or test(s), I understand that this will be explained to me for my concurrence, unless I am not able to express consent and the processing is critical to protect my life and health. I am also aware that the additional procedure(s)/treatment(s) or test(s) may incur cost that will be added to my hospital bill.
15. I am aware that the practice of medicine is not an exact science and that no guarantee or warranty was made as to the result(s) that may be derived from these procedures.
16. I am aware that Makati Medical Center is a teaching facility with training medical Fellows, Residents, Interns, students or other similar individuals. There is a likelihood that these medical trainees may be assigned to participate in the care process. Their participation is within the limit of their professional competence, training, experience or degree of education and are appropriately supervised at all times.
17. I understand that a separate and specific Informed Consent shall be obtained when the planned care includes surgical or invasive procedure, anesthesia, procedural sedation, use of blood and/or blood products, or other high-risk treatment(s)/procedure(s) and/ or when data will be used for research.
18. I authorize MMC to use my personal data for research and quality management
improvement/assurance purposes with the following conditions:
- My privacy and the confidentiality of such data are respected and maintained;
- I may withdraw this consent anytime (when possible, such data will not be used in subsequent analysis) and withdrawal will not compromise my access to hospital services;
- This permission does not constitute a formal written informed consent for study protocols that require such consent;
- When these data are published, anonymity of the data subject and source are ensured.
19. I agree that any cause of action arising from the aforementioned patient confinement, diagnostic examination, and treatment(s) is filed exclusively in the courts of Makati City.
20. I give consent to the following:
- Disclosure of directory information (i.e., assigned room and/or location) to:
- Immediate Family Member(s)
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- Be seen by the Chaplaincy during confinement
21. I am aware that the hospital sends out health-related information which may be beneficial to me. I consent to the use of my personal data for MakatiMed’s marketing and communications programs and/or activities in relation to MakatiMed’s products, services, events, promotions, and offers via email/SMS/direct mail.
22. The hospital provides a free MakatiMed Patient Identification (ID) Card in lieu of other Photo IDs when availing MakatiMed services. I consent to have my photo taken and to the use my personal data for the creation of my MMC ID Card.
23. The consent for items number 20, 21, 22 and 23 will remain in full force until I revoke it in writing.
I acknowledge that I have read this “Information Registration and General Consent” in a language/dialect that I understand, and I can clarify with any hospital staff any question. I can also refer to MMC’s website at https://www.makatimed.net.ph for more details on the hospital’s Data Privacy Notice.
I acknowledge that this Information Registration & General Consent is valid for five (5) years or as deemed necessary.
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