DATA PRIVACY REQUEST FORM

Important: Proof of Identity must accompany this Request Form and in proper cases,
letter of authorization signed by the ward or absentee if there’s any.

Full Name* Date requested*

Address

Contact number * Email address*

Put on the box which applies to you:

Customer/Client Employee Former Employee Intern Business
    Partner

Supplier Job Applicant Representative/Guardian Other/s 
   Please specify:____________

Type of Query

 Access to personal data

 Update or correction of personal data
 Request export of personal data
 Restrict or object to the use of personal data
 Delete personal data
 Question about Privacy Management Program
 Withdraw consent in processing personal data

Please specify request here:

__________________________________________________________________
________________________________________________________________________
________________________________________________________________________

I hereby agree that Delos Santos Medical Center can use my data for the purpose of dealing with
my request, in accordance with the Data Privacy Policy of Delos Santos Medical Center, I
understand that Delos Santos Medical Center may require me to verify/validate my identity before
fulfilling the request.

___________________________
Data Subject

Action Taken:

__________________________________________________________________
________________________________________________________________________

Date Accomplished: ___________

Name and Signature of processor: __________________

Should you have questions or concerns regarding this, you may contact our Data Protection
Officer via email at privacy@dlsmc.ph or you may call us at +63 889-DLSMC (35762) ext.
8828.