Taipei Veterans General Hospital

New Patient Information and Consent Form

Clinic

Veteran’s
Dependent

Employee
Status

Civilian
Veteran

Other
NHI
Medical Record No. □
Family Name First Name M Date
Place of
of
F Birth
birth (Year) (Month) (Day)

Betel nut
Smoking
Y Y Y

History

History

Marital
Status
I D No .
N N N

Household Zip Code□□□

O
Address
Residential Zip Code□□□

TEL
H
Address □same as above

Email Mobile

For Emergency Contact

Date of Approval
Veteran’s Retired
Retirement Letter No.
Use Only TEL:
◎General NHI status: IC NHI card (the ID card is required for inspection if there is no photo on the NHI card） Visit Date
◎Veteran or veteran’s dependent (family representative): IC NHI card, veteran certificate or veteran’s dependent
Certificates certificate, ID card
◎Foreigner: IC NHI card, residence permit (passport)
for ◎Child: household registration certificate, IC NHI card, Taipei or New Taipei City child healthcare card
Verification (with household registered in Taipei or New Taipei City).
◎Patients with serious illness: IC NHI card, serious illness card
◎Other persons eligible for reduced or exempt expenses: IC NHI card, related certificates
1. Personal information collection, processing and use
(1) I agree that your hospital may collect, process or use my medical records and related information for medical treatment, care services or other
specific pupose as follows:
(2) I □ agree □disagree
Under the premise of health and care services, your hospital and branches (Taipei Veterans General Hospital Suao Branch, Taipei Veterans
General Hospital Yuanshan Branch, Taipei Veterans General Hospital Taoyuan Branch, Taipei Veterans General Hospital Hsinchu Branch,
Taipei Veterans General Hospital Fenglin Branch, Taipei Veterans General Hospital Yuli Branch, Taipei Veterans General Hospital
Taitung Branch) may process and use my medical records and related information collected from your hospital and all branches (Taipei
Veterans General Hospital Suao Branch, Taipei Veterans General Hospital Yuanshan Branch, Taipei Veterans General Hospital Taoyuan
Branch, Taipei Veterans General Hospital Hsinchu Branch, Taipei Veterans General Hospital Fenglin Branch, Taipei Veterans General
Hospital Yuli Branch, Taipei Veterans General Hospital Taitung Branch). If consent is not given, the hospital will be unable to process
and use medical records and related information.
2. Use for non-specific pursposes
According to articles 5 to 9, 16 and 20 of the Personal Information Protection Act,
I □ agree □disagree
The hospital may contact you regarding physician service hour changes or on behalf of the clinic, information regarding health education, health
checks, patients’ club, hospital news, outpatient schedule, new medical knowledge, teaching activities, care and satisfaction related information
through letter, e-mail, SMS, fax or telephone. If consent is not given, the hospital will be unable to contact you for the above-mentioned
information.
3. I have read this document carefully and fully understand the contents and agree to abide by the stated conditions. Any objections to this
agreement subsequent to consent being given shall result in the termination of rights for use.

Signature of Consent: Relationship:

Address: Tel:
Date: (Year) (Month) (Day)
Note:
1. For specific purposes as promulgated by the Ministry of Justice, refer to the notes on the back, please.
2. For specific categories as promulgated by the Ministry of Justice, refer to the notes on the back, please.
3. Deliver this completed form along with ID card or driver’s license or NHI card to the counter clerk for handling.

Filed by: MR2-011e

 Specific Purpose and Personal Information Categories of the Personal
Information Protection Act
Specific Purpose
Code Item

012 Public health or prevention of infectious diseases

National health insurance, labor insurance, farmer insurance, national pension
031
insurance and other social insurance
042 Military service, substitute military service administration
058 Social services or social work
The collection, processing and use of personal information by non-public agency
063
pursuant to statutory obligations
064 Healthcare medical services
084 Blood donation services
096 Veterans affairs management services for family member service and care
108 Ambulance service
156 Health administration
159 Academic research
Other business operations within the registered business scope or articles of
181
incorporation
182 Other consultation and advisory services

Personal Information Category

Code Category

C001 Personal identification: name, title, address, telephone, email address

C002 Financial identification: account number and name in financial institution
C003 Governmental identification: ID
C011 Personal data: age, sex, date of birth, place of birth, nationality
C012 Physical characteristics: height, weight, blood type
C013 Habits: smoking, drinking
C021 Family status: married or single, name of spouse
C022 Marriage history: previous marriage or name of cohabitant
C034 Travel and other migration details: migration history, travel details
C038 Occupation
C040 Accident or other event and related conditions
C066 Health and safety records: occupational illness
Health record: medical reports, diagnosis and treatment records, examination results,
C111
physical and mental disability category
C112 Sex life
C131 Written document index