Consent:
FOR HMO USE: (PATIENT-MEMBER)
The patient or his/her authorized representative hereby consents (if patient cannot sign) to the processing and disclosure of the patient’s information by MediCard, its representatives, and its accredited healthcare providers which is necessary for the assessment of the patient’s coverage and the fulfillment of its obligations as health maintenance organization (HMO) services, including treatment of illness. Consent is also given to share utilization data with the Principal Member’s Company (for corporate health insurance) for the proper administration of its health benefits program.
Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to the patient.
The undersigned declares that he has full authority to sign and further acknowledges that the patient is afforded with certain rights and protection in accordance with Republic Act 10173 also known as the Data Privacy Act of 2012 and that he may visit www.medicardphils.com/privacy-notice or email privacy@medicardphils.com for more information.