METRO NORTH MEDICAL CENTER AND HOPSITAL

LABORATORY DEPARTMENT
PRIVACY NOTICE FORM

1. Ask if the patient has already signed a Consent for Processing of Sensitive
Personal Data Sheet.
2. Patient is only given Once for the Consent Form
3. Check the profile of the patient if Consent form is given
4. Tell the patient the Consent Form is needed for the Processing, Releasing
and Storage of Data of the patient (Result, Official Request from MD and
Charge Slip)
5. Patient should fill out the form on the front page
Name of Data Subject – Name of Patient
Age
Birthday
Contact No.
Patient is a minor – State the age of the patient
Signed by – Signature over printed name of the Subject
Date and Time
Witnessed by – Staff Med tech who gave the consent from
6. Give the second, third and fourth copy to patient.
How to input if the Patient is given the Privacy Notice Form

1.Highlight the Name of the patient 2. Select Edit

3.Select Patient Profile 4. Go to Remarks and Input
Privacy Notice Given and
Consented

5. Save and Close