To our Valued Patients and Clients:
In compliance with Republic Act 10173 or the Data Privacy Act of 2012, MyHealth Clinic shall
be requiring all patients and clients, prior to taking advantage of our services, to sign an
“ACKNOWLEDGEMENT, CONSENT, AND WAIVER FORM.”
Please know that this law covers all individuals and entities who are involved in the collection
and processing of personal information. As such, MyHealth Clinic joins other businesses in
requiring patients and clients to sign an Acknowledgement, Consent, and Waiver Form, or other similarly-purposed forms.
MyHealth Clinic firmly emphasizes our fervent
commitment to ensuring the privacy of all our patients and clients,
with the pledge that
Doctor- Patient confidentiality will be maintained always.
Thank you for your understanding and continued patronage.
I have voluntarily executed this Acknowledgement, Consent, and Waiver Form to certify and attest to the following:
I have voluntarily submitted myself to undergo examination/procedure at
in relation to my Pre-Employment Medical Examination, Annual Check Up, Executive Check Up,
Consultation, Laboratory Test/s, Diagnostic Procedure/s and/or other Medical Procedure/s.
I hereby authorize MyHealth Clinic’s Physician/s, and medical staff to perform any examination,
diagnostics, treatment, and/or operative health care procedure that are deemed medically necessary
by this institution.
I am freely, knowingly and voluntarily giving my consent to MyHealth Clinic to obtain, collect, examine,
process and store copies of my personal information, including sensitive personal information,
privileged information, medical records or any information related to my consultation,
treatment or any medical advice. Except as otherwise stated hereon, any information obtained relative
to the authority herein given shall be strictly confidential. The extent of the collection and processing
shall be necessary and incidental to the performance of the service/s availed of.
I agree and understand that my personal information may be used by MyHealth Clinic for purposes,
such as, but not limited to:
the management of my condition;
health management program and activities;
healthcare market research and
other medical-related purposes.
I agree and understand that to comply with its obligations and to provide better services,
MyHealth Clinic may be required to disclose my personal information as requested by its duly
authorized representatives, third-party providers, representatives of sub-contractors
and Health Maintenance Organization affiliates. MyHealth Clinic, however, shall ensure that it has taken
all reasonable actions to limit the information to what is only necessary and required by the other party.
I agree and understand that MyHealth Clinic may retain such personal information within 5 years of
collection to attain the above-stated purposes and as required by applicable laws and regulations
and I hereby expressly and explicitly agree to MyHealth Clinic’s Privacy Statement
I hereby warrant that I understand my rights and obligations pursuant to the Data Privacy Act and its
implementing rules and regulations. I understand that I retain the right to: be informed, to object,
to access, to complain, to rectify, to request for filtering of certain information and to corresponding
damages in case of violation of our rights within the corresponding limitations as set forth in the pertinent laws.
I hereby confirm and agree to hold MyHealth Clinic, its officers, directors, employees, and/or other duly
authorized agents/representatives, free and harmless from and against any and all suits or claims,
actions, or proceedings, damages, costs, and expenses, which may be filed or charged against MyHealth Clinic,
its officers, directors, employees, and/or other duly authorized agents/representatives, in connection with
or arising from the use, processing and disclosure of such information pursuant to MyHealth Clinic’s reliance
on my representation and warranty that MyHealth Clinic and its representatives have the authority to examine,
use, process, store, share, or disclose, as the case may be, said information for the above-mentioned purposes.
I hereby voluntarily execute this Authorization, Consent and Waiver Form with full knowledge of its contents
and consequences pursuant to and in compliance with the requirements of relevant laws, rules and regulations,
including the Data Privacy Act of 2012.
MyHealth Clinic hereby reserves the right to amend this Privacy Statement to comply with government and
regulatory requirements, to adapt to new technologies, to align with industry practices, or for other
legitimate purposes. Rest assured that you will be notified if the amendments are significant.
For questions or concerns about our Data Privacy, please contact our Data Protection Officer thru: