NON-DISCLOSURE AGREEMENT

The Agreement entered into by and between:

The NORTHERN MINDANAO MEDICAL CENTER, a government hospital with address at Capitol
Compound, Cagayan de Oro City, represented in this act by its Medical Center Chief, JOSE C. CHAN, MD,
herein referred to as NMMC, and

_________________________________________, of legal age, Filipino and resident of

_________________________________________, in his/her capacity as medical post-graduate intern,
hereafter referred to as TRAINEE.

WITNESSETH:

WHEREAS, NMMC accepts the TRAINEE who is matched in NMMC to render post-graduate
internship in the hospital as per Association of Philippine Medical Colleges Foundation Inc. (APMCFI)
guidelines and strictly implements the provisions of the Republic Act 10173 or Data Privacy Act of 2012.

WHEREAS, TRAINEE accepts the corresponding responsibilities subject to the condition hereunder
set forth;

NOW THEREFORE, for and in consideration of the foregoing premises, the parties hereby agree as follows:

1. Confidentiality of information. TRAINEE adheres to respect, protect and preserve the

confidentiality of all information obtained, gathered or to which he/she has access in the course
of his/her training in NMMC. This shall mean non-disclosure of all information gathered in NMMC,
except to those who are authorized to receive them under existing hospital rules. This duty to
confidentiality shall extend even after termination of post-graduate internship.

2. Types of confidential information. Included as confidential information are: a) patient health

records, diagnostic test results and pathology reports; b) personnel data and performance
reviews, accounts and financial reports, and internal association records; c) customer satisfaction
survey reports/results; d) selection, promotion and placement board interview results; and e)
other data which result from privileged communications.

3. Forms of confidential information. Information may be in electronic or hard copy formats.

4. Non-disclosure of passwords, access procedures and security protocols. Computer security

systems and all other information technology resources installed within NMMC shall be kept
inaccessible in whatever manner from any outsider, except to those who are officially entrusted
with the same as part of their duties and responsibilities.

5. Violation or breach of agreement. Any violation or breach of this agreement shall result in
disciplinary sanction which may be legally pursued by way of criminal, administrative, or civil
prosecution under the Data Privacy Act or applicable laws.
IN WITNESS WHEREOF, the parties hereunto set their hand this _____________________ in Cagayan de
Oro City, Philippines.

NORTHERN MINDANAO MEDICAL CENTER

Represented by:

JOSE C. CHAN, MD _______________________________

Medical Center Chief II Trainee (Post-Graduate Intern)

ACKNOWLEDGEMENT

Republic of the Philippines)

Cagayan de Oro City )s.s.

BEFORE ME, personally appeared the following who exhibited to me their identification cards as
competent proof identity, to wit:

Jose C. Chan, MD ID No. ___________________

_____________________________ (PGI) ID No. ___________________

Known to me and to me known to be the same persons who executed this foregoing Non-Disclosure
Agreement consisting of two (2) pages inclusive of this page where this acknowledgement is written and
acknowledged to me that same is their free act and deed.

WITNESS MY HAND AND SEAL this ____________________ in Cagayan de Oro City, Philippines.

Doc. No. ___________

Page No. ___________
Book No. ___________
Series of ____________
 GUIDE WHERE TO
FILL OUT/SIGN
EXAMPLE
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NON-DISCLOSURE AGREEMENT

The Agreement entered into by and between:

The NORTHERN MINDANAO MEDICAL CENTER, a government hospital with address at Capitol
Compound, Cagayan de Oro City, represented in this act by its Medical Center Chief, JOSE C. CHAN, MD,
herein referred to as NMMC, and

JUANA DELA CRUZ, of legal age, Filipino and resident of BARANGAY 27, CAPITOL COMPOUND, CAGAYAN
DE ORO CITY, in his/her capacity as medical post-graduate intern, hereafter referred to as TRAINEE.

WITNESSETH:

WHEREAS, NMMC accepts the TRAINEE who is matched in NMMC to render post-graduate
internship in the hospital as per Association of Philippine Medical Colleges Foundation Inc. (APMCFI)
guidelines and strictly implements the provisions of the Republic Act 10173 or Data Privacy Act of 2012.

WHEREAS, TRAINEE accepts the corresponding responsibilities subject to the condition hereunder
set forth;

NOW THEREFORE, for and in consideration of the foregoing premises, the parties hereby agree as follows:

1. Confidentiality of information. TRAINEE adheres to respect, protect and preserve the

confidentiality of all information obtained, gathered or to which he/she has access in the course
of his/her training in NMMC. This shall mean non-disclosure of all information gathered in NMMC,
except to those who are authorized to receive them under existing hospital rules. This duty to
confidentiality shall extend even after termination of post-graduate internship.

2. Types of confidential information. Included as confidential information are: a) patient health

records, diagnostic test results and pathology reports; b) personnel data and performance
reviews, accounts and financial reports, and internal association records; c) customer satisfaction
survey reports/results; d) selection, promotion and placement board interview results; and e)
other data which result from privileged communications.
 3. Forms of confidential information. Information may be in electronic or hard copy formats.

4. Non-disclosure of passwords, access procedures and security protocols. Computer security

systems and all other information technology resources installed within NMMC shall be kept
inaccessible in whatever manner from any outsider, except to those who are officially entrusted
with the same as part of their duties and responsibilities.

5. Violation or breach of agreement. Any violation or breach of this agreement shall result in
disciplinary sanction which may be legally pursued by way of criminal, administrative, or civil
prosecution under the Data Privacy Act or applicable laws.

IN WITNESS WHEREOF, the parties hereunto set their hand this _____________________ in Cagayan de
Oro City, Philippines.

NORTHERN MINDANAO MEDICAL CENTER

Represented by:

JOSE C. CHAN, MD JUANA DE LA CRUZ

Medical Center Chief II Trainee (Post-Graduate Intern)

ACKNOWLEDGEMENT

Republic of the Philippines)

Cagayan de Oro City )s.s.

BEFORE ME, personally appeared the following who exhibited to me their identification cards as
competent proof identity, to wit:

Jose C. Chan, MD ID No. ___________________

JUANA DE LA CRUZ(PGI) ID No. NMMC PGI ID NO. (NUMBERS TO BE POSTED WITHIN THIS WEEK)

Known to me and to me known to be the same persons who executed this foregoing Non-Disclosure
Agreement consisting of two (2) pages inclusive of this page where this acknowledgement is written and
acknowledged to me that same is their free act and deed.

WITNESS MY HAND AND SEAL this ____________________ in Cagayan de Oro City, Philippines.

Doc. No. ___________

Page No. ___________
Book No. ___________
Series of ____________