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Data Privacy Consent Form

The data privacy consent form authorizes AHSCI to collect, use, disclose, store and process the signee's personal data for medical treatment, billing, and other legitimate business purposes as allowed by Philippine law. The signee affirms their rights under the Data Privacy Act of 2012 including rights to access, object and withdraw personal data and seek damages for any violations.

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DPO AHSCI
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© © All Rights Reserved
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422 views

Data Privacy Consent Form

The data privacy consent form authorizes AHSCI to collect, use, disclose, store and process the signee's personal data for medical treatment, billing, and other legitimate business purposes as allowed by Philippine law. The signee affirms their rights under the Data Privacy Act of 2012 including rights to access, object and withdraw personal data and seek damages for any violations.

Uploaded by

DPO AHSCI
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DATA PRIVACY CONSENT FORM

I certify that all information given is true and correct. I hereby authorized AHSCI to collect, record, update,
use, disclose, store, block, erase or destruct my personal data as part of my personal information for purposes
of my medical treatment and services, billing processing, and other purposes necessary for AHSCI to
continue its operations and as may be required for legal, regulatory or legitimate business purposes.

I affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal
data, and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the
Philippines, or Data Privacy Act of 2012 and its Implementing Rules and Regulations.

Signature over Printed Name Date

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