CONSENT

I hereby consent to engaging in AHMC Appointments with my selected doctor.

I understand that "AHMC Appointments" includes the practice of remote health care service delivery, including consultation, diagnosis, treatment, transfer of medical data, and health education using interactive audio, video or other telecommunications technology.

I understand that AHMC Appointments also involves the communication of my medical information, both orally and visually, to health care practitioners necessary for health care service delivery. I also understand and agree that nonmedical technical personnel may be present to aid in the interactive audio, video or other telecommunications technology transmission.

SCOPE AND LIMITATION

I understand that this extraordinary service is being introduced during the time of the CoViD-19 pandemic as a stopgap measure to help provide safe, compassionate, and professional health services access and options for healthcare practitioners and patients who are under quarantine, or whose movements may be limited by community quarantine rules and their current personal circumstances. This service it is not intended or claimed to fully replace the usual and traditional face-to-face consultations done between a patient and a doctor.

Due to the remote nature of the AHMC Appointments service, Direct physical examination by the healthcare professional will not be possible except for limited visual and auditory observation of the patient via audio / video stream technology and appreciation of patient-entered and measured values of vital signs readings made by the patient or any third party authorized by the patient.

DISCLOSURE

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

The laws that protect the confidentiality of my medical information also apply to AHMC Appointments. As such, I understand that the information disclosed by me during the course of my consult is strictly confidential, unless otherwise provided by law.

I understand that there are risks and consequences from AHMC Appointments, including, but not limited to, the possibility, despite reasonable efforts on the part of my Doctor, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be interrupted or accessed by unauthorized persons.

In addition, I understand that AHMC Appointments based services and care may not be as complete as face-to-face services, such as limitation in the conduct of physical examination, and I fully accept the risks consequential thereto.

I understand that the information that I will be providing must true, correct, and complete as of the date hereof, and if there should be any changes in this information, I will immediately provide Asian Hospital and Medical Center with that information in writing.

DATA PRIVACY

I understand that I have a right to access my medical information and copies of medical records in accordance with the Data Privacy Act of 2012 or RA 10173.

I also understand that the dissemination of any personally identifiable images or information from the AHMC Appointments interaction to researchers or other entities shall not occur without my written consent.

I understand and agree that I will not record the AHMC Appointments session nor publish online or otherwise, any recording, made of the AHMC Appointments without the prior written consent of the Physician being consulted on this platform and Asian Hospital and Medical Center.

I understand and agree that Asian Hospital and Medical Center may use data from this AHMC Appointments to pursue its goal of improving the value and benefits of this service but that any publication of patient data will have personal identifiers removed or anonymized or hidden, and that my data will only be published in aggregate reports which do not contain my personal identifiers unless I provide written consent to do otherwise.

ADMINISTRATIVE

I also understand and agree that nonmedical technical personnel may be present to aid in the interactive audio, video or other telecommunications technology transmission.

I understand that there may be delays in the consultation due to the hospital’s skeletal workforce implementation.

I also authorize Asian Hospital healthcare team to get in touch with me should there be a medical need to do so in the interest of my safety or the safety of others.