-~"5 Gleneagles Hospital REQUEST FOR ee” cca ninasaiu MEDICAL INFORMATION Dear Sir / Madam, Gleneagles Kota Kinabalu (GKk) a healthcare facility, owned and managed by Gleneagles Kota Kinabalu Branch (c/o Pantai Medical Centre Sdn Bhd) maintains strict confidentiality on its patients’ medical records. ‘Access to the medical information can only be released with the written consent from the patient or next of kin or unloss ordered by court WHO CAN REQUEST? >” Patient who is above eighteen (18) years of age ; > Ifthe patient is mentally or physically disable, the spouse, parent ; or | > Ifthe patient is unmarried and below eighteen years of age, parent or legal guardian |» Fordeceased patients, a certified true copy of the patient's death certificate, & Letters of Administration | (where no will was made by the deceased) or Grant of Probate (where a will was made by the deceased), Whichever applicable, as proof of relationship to the deceased must be submitted with the application, > Third parties with a valid written consent from the patient. | How To APPLY? | A) In Person Please proceed to Medical Records Department | Level 2, Block A-1, Lorong Riverson @ Sembulan, 88100 Kota Kinabalu, Sabah. Reques! for reports / medical information can be made during these hours: | Monday to Friday £8.30 am. 1.00 p.m. , 2.00 pam. - 5.30 p.m. | Saturday 8.30 am.~1230pm Contact 1088 518 864, my.gkk. medicalrecords@parkwaypantai.com 8) ByMail Complete the “Consent for Release of Medical Information’ at the back of this form. For insurance claim, please enclose insurance cialm form, complete relevant section of the form and append your signature in the authorization section of the claim form, (Note: We can only process afer the patient / next-o-kin has signed the authorization section). CHARGEABLE REPORT FEES. Description | without prior notice at GKK discretion) Non Specat/ MascalOrcer | Mion Tinea Medel RepeR, Ty gp ro | __—Finsurance Claim Form [RMs07RM 0 i Hdl Repo 106-250 pecialist RM 500 - RM 2500 (depending on the Legal Report 7 required paper work for legal purpose) ctr charges ° (Fees Payable (RM) subject to change | Description without prior notice at GKK discretion) For copies of ab resus, diagnostic, imaging, discharge summaries etc. _| RM10 Administrative Fee aOR (iin Way Courier Feo For andi oa copies io eqns | RUT RTE TN We) {if required) pecouier depend on the given location. Parent moDe ‘A. By Cash / Credit Card |B. By Cheque", made payable to GLENEAGLES KOTA KINABALU . By Bank In /Online Transfer: CIMB Bank Berhad. Account Name: Gleneagles Kota Kinabalu, Account Number: 8001148022, SWIFT code: CIBBMYKL. | ** Note: For Personal Cheque / Bank in / Online Transfer, Please note that the completed report and receipt will only be released upon clearance of cheque / receipt of payment by Gleneagles KK's Finance Department Explained By (staff name) Explanation Given To (spectty name) Page 10 (GKK/SS/REQUESTMEDICALINFORMATION2020102{ -"“2 Gl ii CONSENT TO RELEASE zo Gleneagles eel MEDICAL INFORMATION arkway Pantal Group and their representatives andlor agents collecting, Saree acosing my persona data to provide me for administrative work and other reasonably related pupones, Sesh preenes ‘re Set outin the in Data Privacy Poy, accessible at htas:/www gloneagles.com myjegalirvacypolcy of avaabie on rancor src ceatam fata personal tat have proved areal rue, update and accurate, Should there be any changes to any of fea peone Gata. shal noty Parkway Paniai Group mela. understand that may wtharaw such convent aay tne oe Fors avaiable on request from our staff OR by email to Chef Privacy Officer at my.mod.opo@parhweypentaicern Frei must Be uly completed an saned by the patent. te patents Dolow 18 yeas of ape he Orr tte hereby consent ress) and authorize Gleneagles Kota Kinabalu fo provide information contained in the medical records of ‘myself / patient Patients Name: INRIC / Passport No: — | pn — Type of Admission: 0 inpatient Outpatient Emergency 0 Others Date of Visit to. __ for use forthe purpose mentioned below (Name a ation or ndvidual) Oinsurance Claim — CO Continuty of Care Legal Purpose Others :__ |Murther authorize Gleneagles Kota Kinabalu and its officers to release the medical report to: to NRICPassport No: Name and Address of Organization ov Waive | Contact No. Email Address ‘Who will receive this report on my behalf (“mysel/patient) Besides the medical report fee, | undertake to pay any additonal charges suchas laboratory reports or Imaging reports, which ‘may be incurred in the preparation ofthe report * With this, | release Gleneagles Kota Kinabalu, the attending doctor/consuitant and its staff from al legal responsibilities Cr labities that may arise from the act hereby authorised, | ° [shall itevocably waive all my legal rights and remedies against Gleneagles Kota Kinabalu and shall not demand or Clim against Gleneagles Kota Kinabalu for any loss, damage, expenses andlor costs which may arise from the et Dereby authorized, | hereby agree to keep you indemnity against all actions, claims, proceedings, coss, damages and crpenses (including legal costs on the fll indemnity bass) which the said hospal may incur or sustain by reason of any of the above matters. | O To Collect by Hand Name of Person a Tol. No (1D To Deliver by Post Name of Person Tel. No Postal Address —E a “Patient / Pationts Parent] Next-of Kin ‘Signature / Name & NRIC I Passport of Win (be person presen during ine ing Page 28