ST. LUKE'S MEDICAL CENTER PRIVACY CONSENT FORM

St. Luke's Medical Center (SLMC) values your data privacy and ensures that your Personal Data are collected, used, retained, shared and disposed in adherence to the general principles of transparency, legitimate purpose, and proportionality.

1. 1. WHAT WE COLLECT: SLMC shall collect Personal Data which is comprised of your Personal Information (such as name, signature, and contact details) and your Sensitive Personal Information (such as previous and current health information, medication, and treatments).
2. 2. PURPOSE: I agree to the collection, use, retention, and sharing of my Personal Data to conduct acts, omissions, evaluations, and decisions for the following purposes:
   1. i. To diagnose, treat, medicate, and prognose your medical or psychiatric condition, history, and tendencies performed by multidisciplinary treatment teams. These include performing medical acts and services, ancillary services, and related care necessary or reasonably convenient to accomplish medical and allied healthcare objectives.
   2. ii. To observe, capture, record, chart, evaluate, analyze, interpret, profile, correlate, cross-reference data gathered and observed from you and your state to formulate options and conduct measures related to your life, health, and wellness. This includes conducting, evaluating, and storing examinations, tests, procedures, operations, prescriptions, and providing medical advice.
   3. iii. To perform acts, duties, roles, and obligations customary to and expected from healthcare providers, hospitals, and similar institutions. This includes sharing your Personal Data to outsourced laboratories, consultants, visiting doctors, Health Maintenance Organizations (HMOs), and collaborating healthcare providers.
   4. iv. To make decisions necessary to preserve, protect, prolong, or improve your health and safety. This includes sharing your Personal Data to consultants, visiting doctors, and collaborating institutions or practitioners.
   5. v. To perform functions of a research and teaching hospital. This includes sharing your Personal Data to researchers, faculty, and interns.
   6. vi. To reach out to your contact details to provide reminders and information on scheduled appointments, details of your succeeding care, additional services that may be relevant to you, and updates in the services of St. Luke's Medical Center.
   7. vii. To gather and analyze data for rectification or improvement of our services. This includes internal investigations, market research, and improvement of patient experience.
   8. viii. To facilitate the performance of legal obligations, relationships, and transactions with you. This includes processing and transmission of forms, contracts, billing statements, and other documents arising from our engagement.
   9. ix. To inform your relatives and related persons of your medical and psychiatric condition.
3. 3. EMERGENCY PROCEDURES. We legally do not require your or anyone's consent to perform emergency or urgent procedures to save or protect your life and health.
4. 4. DISCLOSURE AND SHARING. Personal data under the care, custody, and control of SLMC shall be disclosed only pursuant to a legitimate purpose, and to authorized recipients of such data. Your data and Personal Data will be disclosed primarily to all members of SLMC who are involved in providing you care. It will also be shared to government agencies pursuant to applicable laws and regulations. As part of our business operations, SLMC may also share your Personal Data to select partners and vendors covered by appropriate privacy agreements and contracts.
   You have a right to access your own personal data. In case of your death or incapacity, your heirs shall have the right to access your personal data.
5. 5. HEIRARCHY OF DECISION MAKERS. In case of your incapacity, a sole individual who is available to validly sign documents and with no legal or mental restrictions to decide for your care shall be identified as your only decision maker. The following hierarchy shall be followed in identifying your surrogate decision maker:
   1. Your legitimate spouse;
   2. Your legitimate and legally recognized children of legal age, the hierarchy starting with the eldest;
   3. Your parents. In case of disagreement, the hierarchy in the Family Code shall be followed.
   
   If you do not wish the above hierarchy to be followed for your decision maker, please appoint an authorized representative or relative to make decisions on your behalf in case you are incapacitated:
   

   Authorized Representative or Relative (Optional) - To make decisions on your behalf in case you do not want to follow the hierarchy of decision makers above:

   Name

   Relationship

   Phone (preferably mobile)

   Email or secondary phone

   Invalid Email

   Please note that we may still process your personal data in accordance with the Data Privacy Act of 2012, including allowed acts of processing to protect your life or health. Rest assured, individuals authorized with the care, custody, control, and access to your data and Personal Data operates under strict confidentiality.

6. 6. VALIDITY OF CONSENT: The consent that you give to SLMC shall be valid fifteen (15) years from the last occurrence of any of the following: (a) your last consultation with or availment of services in SLMC; (b) your Personal Data was used by SLMC for evaluation of your medical or psychiatric condition; or (c) a legal need of SLMC to retain your Personal Data, including furtherance of SLMC's legal claims or defenses.
7. 7. STORAGE AND RETENTION. SLMC implements appropriate security measures in storing collected data and Personal Data. Data and Personal Data within the care, custody and control of SLMC shall be retained for as long as the data subject regularly seeks treatment at SLMC. Printed copies of data and Personal Data which are more than five (5) years old shall be archived at a secure facility. After an inactive period of fifteen (15) years from the last engagement, consultation or confinement, these printed copies shall be brought to an appropriate facility for its proper disposal. Electronic records with data and Personal Data shall be retained in a similar period and manner.
8. 8. RIGHTS OF THE DATA SUBJECT: SLMC shall at all times uphold the following rights of the data subjects: Right to be informed, to access your Personal Data, to object or withdraw your consent, to erasure or blocking, to damages, to rectify, to data portability and to file a complaint with the National Privacy Commission.

Any questions or clarifications regarding data privacy and protection may be directed to our Data Privacy Officers:
SLMC Quezon City: dataprivacy.qc@stlukes.com.ph or SLMC Global City: dataprivacy.gc@stlukes.com.ph