Associated Marine Officers and Seamen s

Union of the Philippines PTGWO – ITF

(An Affiliate of the International Transport
Workers Federation London, UK)
SEAMEN S HOSPITAL
Cabildo corner San Jose Sts., Intramuros, Manila
Tel No. (+632) 5278116 to 20 * 5232692 Telefax (+632) 5273554
Email: shospadm@gmail.com
Consent Form
Telehealth

I. FOREWORD IV. RESEARCH CLAUSE

A. The AMOSUP Seamen s Hospital values every individual s privacy.
B. In order to process your request, AMOSUP Seamen s Hospital
Telehealth unit would need to take certain data from you which can be
classified as either Personal Information or Sensitive Personal
Information under the Data Privacy Act of 2012.
C. AMOSUP Seamen s Hospital Telehealth Unit would only collect data
classified as Personal Information or Sensitive Personal Information
with your consent or in others exceptional cases provided by law.
D. AMOSUP Seamen s Hospital Telehealth Unit will only use the data it
has collected from you for lawful purposes.
E. If you allow AMOSUP Seamen s Hospital Telehealth Unit to collect
your Personal Information and Sensitive Personal Information, please
manifest your consent in this document which shall be referred to as you
CONSENT FORM .
II. DEFINITION OF TERMS:
 Data Subject refers to an individual whose personal, sensitive
personal, or privileged information is processed.
 Personal Data refers either to Personal Information or Sensitive
Personal Information as defined in the Data Privacy Act and its
Implementing Rules and Regulations.
 Personal Information refers to any information whether recorded in a
material form or not, from which the identity of an individual is apparent
or can be reasonably and directly ascertained by the entity holding the
information, or when put together with other information would directly
and certainly identify an individual
 Sensitive Personal Information refers to personal information:
1. About an individual s race, ethnic origin, marital status, age, color,
and religious, philosophical or political affiliations;
2. About an individual s health, education, genetic or sexual life of a
person, or to any proceeding for any offense committed or alleged to
have been committed by such person, the disposal of such proceedings,
or the sentence of any court in such proceedings;
3. Issued by government agencies peculiar to an individual which
includes, but not limited to, social security numbers, previous or cm-rent
health records, licenses or its denials, suspension or revocation, and tax
returns; and
4. Specifically established by an executive order or an act of Congress
to be kept classified.
III. DATA TO BE COLLECTED AND PURPOSE
AMOSUP Seamen s Hospital Telehealth
FOR THE PURPOPSE/S
NEEDS TO COLLECT THE F F:
Some of the persona l d ata (indi cated abo ve) you wil l pro vid e in the Membership
Form will be used to gen erate statistical rese arch O NL Y for the p urpose of
improving the ser vices a nd benefits of AMO SUP to its me mb ers.
Rest assur ed tha t if your personal da ta will b e i nclu ded, non e o f yo ur p ersonal
information th at will i dentify you will be involved.
V. HOW WOULD YO UR PERSONAL DETAILS BE P RO CE SSED
Documents co nta ining your personal details sh all b e stored in se cu re facilities
which i nclu de among others lo cked fi ling ca binets which may be accessed only b y
authori zed AMOS UP emplo yee s. AMOSUP employee s authorized to a ccess are
covered by a confidentiality an d n on-disclosure agreemen t. The details
enu me rate d a bove shal l be retain ed for only as ne cessary for th e p urpose/s stated
in acco rdance wi th its Data Retention Policy.
VI. CONFIDENTIALITY AND DISCLO SURE
Onl y authorized AMOSUP person nel sha ll b e g ranted access to process th e d ata
you have p rovided.
However, your personal da ta will a lso be disclosed to the foll owi ng branches /
institutions for the purpo se/s writte n h erein.
 Wit hin AMOSUP De partm ent s – for coo rdination of A MO SUP b enefits
 AMOSUP Seame n s Hospital Branc he s – for med ica l concerns
 Law enforcement an d g ove rnment ag encies pe rfor min g their go vern me nta l an d
investig ato ry function s.
VII. RIG HTS OF MEMBERS AS DATA SUBJ ECT
As Data Subje ct you ha ve the follo win g r ights:
A. Right t o be informe d. As a da ta subject you have the rig ht to b e in formed ho w
your personal de tails are being pr oce ssed by A MO SUP.
B. Right t o Obje ct. As d ata subje ct you have th e r ight to object to the pro cessing
of your pe rson al data.
C. Right to Acces s. As d ata subje ct you have th e r ight to access an d view the
information yo u h ave pr ovid ed.
D. Right t o Rectific ation. As d ata subje ct you have th e r ight to cor rect any
inaccuracy re garding your person al d ata an d ha ve the sa me corrected.
E. Right t o Erasure or Block ing. As d ata subje ct you have th e r ight to withdra w
your co nse nt and ha ve the same destroyed and erased fr om AMOS UP s filing
system.
F. Right t o Damages. As d ata subje ct you shall be indemnified for any da ma ges
sustain ed due to such in accura te, incomplete, outdated, false, unla wfully obtained
or unau tho rize d u se of p ersonal data, taki ng i nto account a ny violation of hi s or her
righ ts a nd free doms as data subje ct.
VIII. CONTACT INFO RMATION OF DATA PRIV ACY OFFICE
To kno w more of AMOS UP Se amen s Hospital s Data Privacy Policy, or if you
want to exercise your rights, or if you have any comments abou t th is form, you
may contact the Data Protectio n Team ;
A. Via Physical Mail to be sen t at:

 Patient Name
 Age
 Attending Physician
 Concern
 Relationship to member
 AMOSUP ID
 Member s Name
 Member s Rank
 Seaman s Book
Such as but not limited to: Associa ted Marin e O fficers and Se amen s Union of the Ph ilippine s (AMOSUP),
 For identification; Sea me n's Hospital, Cabildo corne r S an Jose Streets, Intra mu ros, Manila; or
 For medical purpose; to properly
address the patient s health B. Via Ele ctronic Ma il to be se nt to o r call at:
concern
 For visual identification;
 To verify the identity and the
Privacy Office e-mail: dpo.ashm@gmail.com
legitimacy of being an AMOSUP Privacy Office contact number: 852 7 8 116 to 20 loc. 207 7
member;
 For assessing and evaluating Plea se use th e subje ct: DPA DATA SUBJECT REQ UE ST
membership to the Union;

 Vessel name VI. AUTHORIZATIO N

 Manning Agency
 Onboard Date
 Disembarked Date
 Dependent s ID
 Allotment Slip
 Contact number

Address
 To verify if the vessel is a
I HEREBY AUTHORIZE THE ASSOCIATED MARINE OFFICERS AND
member of AMOSUP and has
active CBA and to update their 201 SEAMEN S UNION O F THE P HILIPP INES (AMOSUP) SEAMEN S HOSPITAL
file in AMOSUP database TELEHEALTH TO COLLECT AND P RO CE SS THE PERSONAL DATA
 For identification of dependent/ ENUME RATED IN P ARAGRAPH III
beneficiary;
 For acknowledgement of
member s dependent for hospital
I AGREE
benefits;
 To contact members for
communication purposes;

SH – THU 001
REV 0 – 09/08/2023