St.

Luke’s Medical Center

Privacy Consent Form
For CIF

St. Luke’s Medical Center (SLMC),as the Personal Information Controller (PIC), respects and values your data privacy and
ensures that all data and information from the data subjects are collected, processed, retained, and disposed in
adherence to the general principles of transparency, legitimate purpose, and proportionality.

SLMC shall collect your Personal Information (such as your Photo, Name, address) and your Personal Sensitive information
(such as your marital status, age, previous and current medical records, medication or treatments) as contained on
your submitted Case Investigation Form (CIF).

The main purpose of collecting these information is to meet your medical and ancillary needs or requirements. Aside from this,
we collect and process your information for Identification purposes; Payment of your bills, coordination of the service that
you are availing or has availed; to liaise with health professionals and HMO’s; collaboration with other medical health
provider (where necessary); for use in internal investigations; For analytical, historical, statistical purpose; and
purposes required by law.

Personal data under the care, custody, and control of SLMC shall be disclosed only pursuant to a legitimate purpose, and to
authorized recipients of such data. Your data and information will be disclosed primarily to all members of SLMC who are
part of the team providing you care. It will also be shared to government agencies pursuant to applicable laws and
regulations. It may also be shared to authorized third parties for purposes of verification of test results either through the QR code or
through SLMC contact channels and pursuant to our verification guidelines.

We may also disclose and share your information to the following: (Please put the word “Yes” on those you want to give
consent to. Any erasures should have your countersign).

To your immediate family member:

To your authorized representative / legal guardian / partner:
To your company – for Executive check-up,annual physical exam, or Company
requirement.
To other entities for your specific needs: _______________________

I request and authorize SLMC to include the following information (and necessary related information) in the main result
which may be disclosed to authorized third parties for the purpose of verifying test results: (write other information to be
included or indicate “N/A”)

SLMC implements appropriate security measures in storing collected data and information. Data and information within the
care, custody and control of SLMC shall be retained for as long as the data subject regularly seeks treatment at SLMC.
Printed copies of data and information which are more than five (5) years old shall be archived at a secure facility. After an
inactive period of fifteen (15) years from the last engagement, consultation or confinement, these printed copies shall be
brought to an appropriate facility for its proper disposal. Electronic records with data and information shall be retained in a
similar period and manner.

SLMC shall at all times uphold the following rights of the data subjects: Right to be informed, to access your information, to object
or withdraw your consent, to erasure or blocking, to damages, to rectify, to data portability and file a complaint with the
National Privacy Commission.

Any questions or clarifications may be brought to the attention of the SLMC Data Privacy Office at
dataprivacy.gc@stlukes.com.ph or dataprivacy.qc@stlukes.com.ph.

I have read this form, understood its contents and give my consent to the processing of my personal identifiable
information. I understand that my consent does not preclude the existence of other criteria for lawful processing of
personal data and does not waive any of my rights under the Data Privacy Act of 2012 and other applicable laws.

Signature above Full Name / Fingerprint Date