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    Letter of Consent

    Uploaded by

    richard
    This form authorizes Penang Adventist Hospital to release medical reports to applicants. It must be completed by the patient or their legal guardian if the patient is under 18, or next of kin if the patient is deceased. The applicant agrees the hospital is not liable if reports are released via email or fax. The consent is valid for 90 days from signing. The form collects patient details and the applicant's declaration of what reports they authorize to be released and to whom, as well as their signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Letter of Consent

    Uploaded by

    richard
    320 views1 page
    This form authorizes Penang Adventist Hospital to release medical reports to applicants. It must be completed by the patient or their legal guardian if the patient is under 18, or next of kin if the patient is deceased. The applicant agrees the hospital is not liable if reports are released via email or fax. The consent is valid for 90 days from signing. The form collects patient details and the applicant's declaration of what reports they authorize to be released and to whom, as well as their signature.

    Original Description:

    letter of consent of Hospital

    Original Title

    letter_of_consent

    Copyright

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    This form authorizes Penang Adventist Hospital to release medical reports to applicants. It must be completed by the patient or their legal guardian if the patient is under 18, or next of kin if the patient is deceased. The applicant agrees the hospital is not liable if reports are released via email or fax. The consent is valid for 90 days from signing. The form collects patient details and the applicant's declaration of what reports they authorize to be released and to whom, as well as their signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    320 views1 page

    Letter of Consent

    Uploaded by

    richard
    This form authorizes Penang Adventist Hospital to release medical reports to applicants. It must be completed by the patient or their legal guardian if the patient is under 18, or next of kin if the patient is deceased. The applicant agrees the hospital is not liable if reports are released via email or fax. The consent is valid for 90 days from signing. The form collects patient details and the applicant's declaration of what reports they authorize to be released and to whom, as well as their signature.

    Copyright:

    © All Rights Reserved
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    Instruction:

    This form must be completed and signed by the Applicant who may be the Patient or the Parent/Legal Guardian (if the
    patient is below 18 years of age) or the Next of kin (if the patient is deceased) to authorise the release of report(s) by
    Penang Adventist Hospital.
    Note:
    It is the policy of Penang Adventist Hospital that information regarding a patient is releases only in person to protect
    confidentiality. In requesting for report(s) via email/fax, the applicant agrees and releases Penang Adventist Hospital
    from any risks or liability that may occur when using email/fax. This consent form is valid for 90 days from the signed date.
    PATIENT’S PARTICULARS
    Given Name (as in NRIC/Passport):_______________________________________________________________________________
    NRIC/Passport No.:______________________________________________ Hospital Number:______________________________
    Period of Attendance / Admission in PAH :_________________________________________________________________________

    DECLARATION BY PATIENT / APPLICANT

    I, ______________________________________________________ NRIC / Passport No.: __________________________________


    hereby authorise Penang Adventist Hospital to release the following report(s):
    Type of Report:
     X-Ray Report  Discharge Summary  Pap Smear Report  Laboratory Report  Medical Report
     Insurance Form  Others (Please specify): ________________________________________________________
    Purpose of Request:

     Continuity of Care  Insurance Claim  Insurance Application  Legal Proceedings  Second Opinion

     Healthcare Facility: _____________________________  Others (Please specify):_________________________________


    By :
     Hand  Email: ______________________________  Fax : ________________________________
     Postal Mailing Address:_____________________________________________________________________________________

    To : Following person / Agent / Company / Insurance Company/Healthcare Facility OR  Myself

    MALAYSIA
    __________________________________________________ NRIC/Passport No.: _______________________________________
    (Name)
    Date: ______________________________________________ Contact No: ____________________________________________

    Name of Applicant: ___________________________________ Signature of Applicant: ____________________________________

    NRIC/Passport No.: ___________________________________ Relationship to patient: ___________________________________

    RECEIPT BY DATE: RELEASED BY DATE:


    Name: _________________________________________ Name: _________________________________________

    Signature: ______________________________________ Signature: ______________________________________

    NRIC/Passport No.:_______________________________ Employee No.:___________________________________

    0917 V2 CRMDRP MEDR

    PENANG ADVENTIST HOSPITAL


    PATIENT’S LABEL
    CONSENT TO RELEASE INVESTIGATION/
    MEDICAL REPORTS

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