3993 G/F Crosswind Ocean Hotel, Airport Road corner 1474,

L. Gabriel, Baclaran, Parañaque City, 1702, Metro Manila

Tel. Nos.: 8059318 *8160205
Email: info@ssmchealth.com Website: http://ssmcgroup.ph/

73515
REFERRAL FORM

Cost Center: “GAMING” Validity Date: 3 Days from the Date of Endorsement
Department: TABLE GAMES

PERSONAL INFORMATION
Name: Gender: Age:
Address: Birthday:
Mobile No.: Email: Civil Status:
Company: BLOOMBERRY RESORT & HOTLES INC. Nationality:

Contact Person in HR: Email: Contact No:

PROCEDURES

Consultation/Treatment PEME PACKAGE FOR ADDITIONAL PROCEDURES

RESORT NON- FOOD
HANDLER
POSITIONS
Laboratory Test BASIC 5 • Drug Test (Shabu &
Marijuana)
Pre-Employment/Medical Examination 1. Physical Examination with Ishihara Test • ECG (for 35 y/o and above)
Annual Medical examination 2. Complete Blood Count (CBC) • Pregnancy Test for Female FOH only
3. Urinalysis
CHARGE TO: 4. Fecalysis
Company 5. Chest X-RAY
Employee
HMO
Retainer Service
Salary Deduction
REMINDERS
1. Thumb-sized stool should be collected at home, not more than one (1) hour prior assigned schedule.
2. Pre-employment Applicants subject for Drug Testing must bring valid ID (School ID, Company ID, UMID ID, Postal ID, Voter’s ID, Police Clearance, NBI Clearance,
Driver’s License, PRC License, and Passport).
3. Result will be released within 24 hours after all required examination has been completed and forwarded to the concerned company
Angelie Nery J_ayvenn_A_n_to_n_io_____________
PREPARED BY: APPROVED BY:
PRIVACY NOTICE
The SSMCHEALTH, Inc. is a DOH licensed, SEC and ISO certified clinic that provides a system of health care II. Data Subject Rights
services with due consideration to technology, efficacy, quality, cost, advocacy, and environment that
promotes excellence. It also aims to deliver a client centered institution and assures to comply with its Under RA10173, people whose personal information is collected, stored, and processed are called data
obligation on Data Privacy, as stated in Republic Act No. 10173, otherwise known as the Data Privacy Act subjects. Organizations who deal with your personal details, whereabouts, and preferences are duty- bound
of 2012 (DPA), Its Implementing Rules and Regulations and other relevant data privacy laws. to observe and respect your data privacy rights. A good explanation of them is available on
https://www.privacy.gov.ph/know-your-rights/#topic7_part2
SSMC Health Inc. encourages you to review our privacy notice regarding the data processing rules and
practices described in this privacy notice. By filling out the Referral Form you agree to the collection and This Privacy Notice is intended to provide you with information about what personal data the
use of information in accordance with this policy. SSMCHEALTH Inc. collects about you and how it is used. If you have any questions, please contact us
at SSMCHEALTH DPO Email address: ssmchealthdpo@gmail.com
I. Data Processing
Questions, concerns, or complaints
SSMCHEALTH, Inc. processes and objectives in connection with the collection of data are guided by the RA
No. 10173 (DPA act of 2012) which is in line with the principles of transparency, legitimate purpose, and
proportionality.
Please contact the SSMCHEALTH’s Data Protection Officer:
Data Collection
ROCHEE V. TANYAG
When you fill out this Referral Form, we collect information about you including (but not limited to) your SSMCHEALTH Inc.
name, your employer’s name, your address, and your email address. We may also collect your personal 3993 G/F Crosswind Ocean Hotel, Airport Road cor. 1474, L. Gabriel,
email address, a personal mailing address, and a mobile phone number. Further information may be Baclaran, Parañaque, 1702 Metro Manila
collected when you submit a request or contacted SSMCHEALTH’s DPO for any reason regarding your SSMCHEALTH DPO Email Address: ssmchealthdpo@gmail.com
personal data or report a violation or complaint in accordance with your Data Privacy Rights. CP No.: 09167041039

Data Usage
Conforme:

SSMCHEALTH Inc. processes your data to provide you with the services you have requested. We may use
this information to refine our services to better tailor them to your needs and somehow to communicate
with you about other services the SSMC offers.

Data Sharing, Storage and Protection

Signature Over Printed name of the Examinee Date Signed
Your personal information, x-ray, laboratory results and a copy of your identification card will be securely
stored in our computer. The personal information we gathered from you will be stored in a secured location
in our clinic. Only selected competent staff of SSMCHEALTH Inc. will be allowed to access your personal
data and upon completion of the appropriate medical/physical examination, your personal data together
with your medical results will undergo data encryption and will be sent to the company you have applied
for and will be used/processed by your prospected employer in connection with your application to their
company.

Data Retention

Your personal data is stored at the SSMC on its servers, and on the servers of the cloud-based database
management services the SSMC engages. For more information on where and how long your personal data
is stored, and for more information on your rights of erasure and portability, please contact the
SSMCHEALTH’s Data Protection Officer.

LOCATIONS OF OTHER SSMCHEALTH SYSTEM NETWORK:

SSMCHealth - Rosario ,2nd Floor, Andico Bldg. Gen. Trias, Drive, Rosario Cavite *SSMCHealth - Sta. Rosa, Old National Highway (in front of PNB) Balibago, Sta. Rosa, Laguna *SSMCHealth - Calamba, J . Alcasid Business
Ctr,Crossing, Calamba,Laguna *SSMCHealth - Muntinlupa, 3F, Sycamore Centre (in front of Honda Cars - Alabang) Buencamino St. , Cupang,Muntinlupa City