QLINIC MEDICAL CERTIFICATE VALIDATION SLIP DATA PRIVACY CONSENT FORM

MEDCERT NUMBER DATE OF SUBMISSION

PATIENT DETAILS:
FULL NAME
QID #
IMMEDIATE SUPERVISOR
LOB
CONTACT NUMBER
PERSONAL EMAIL ADDRESS
BIRTH DATE
WORK LOCATION
MEDCERT/S DETAILS:
Intellicare Accredited Clinic/hospital/doctor?
Intellicare Account number:
Start date of absence:
End date of absence:
Expected date to return to work:
Number of Date/s absent:
QLINIC STAFF USE:
By signing this consent form, I hereby make my personal data available to Quantrics, its
affiliates, related entities and partners and to process the personal data and retention of
the same.
Maria Victoria A. Cepe
I hereby authorize Quantrics to conduct a validation of the medical certificates and
603722 information I provided. I hereby grant authority to the bearer of this instrument to
FULL NAME access or be provided full details of my medical records and to process and disclose
Edmund Alberto personal information, sensitive or otherwise. I hereby warrant that my consent is freely
CTI Quad Intercept given and is an informed indication of my will.
09217308166 I have read this form, understood its contents and consent to the processing of my
darlingagento@yahoo.com personal data. I understand that my consent to the process of my personal data. I
understand that my consent does not preclude the existence of other criteria for lawful
March 30, 1976 processing of personal data and does not waive any of my rights under Data Privacy Act
of 2012 and other applicable laws.
WFH x On-Site
Maria Victoria
Signature over Printed Name: ________________ A. Cepe
March 25, 2024
Date: _________________
x YES NO
43-00-00128-15813-00
March 20, 2024
March 22, 2024
march 26, 2024
3 days

VALID YES NO Reason for invalidation:

COVERED SL YES NO Covered Dates:
Other Notes:

Version 2.0 September 2023

For Internal Use