EMPLOYEE CONSENT TO RELEASE PERSONAL MEDICAL INFORMATION

(For Financial Assistance from the Medical Assistance Fund)

I, _____________________________, is applying for a financial assistance from the Asialink Group of

Companies’ Medical Assistance Fund. For this purpose, I hereby give my consent for the Human Resources
Department of Asialink Group of Companies to access, secure, collect, obtain and to process any and all
financial records and information pertaining to the “Personal Medical Information” or obtain a medical
record(s) on the state of health and fitness including the costs of my hospitalization, emergency room and
confinement, room and board, medical supplies and medications, consultations and physician’s fees,
laboratory and diagnostic procedures, surgeries, operations, therapies, treatments, and other similar medical
procedures or items which my dependent/relative, _________________________have come to avail or is
planning to avail.

I also hereby consent for the Human Resources Department to share, release, transfer, disclose, divulge and
circulate the above-mentioned Personal Medical Information to and among the various companies and
departments of Asialink Group of Companies for the purpose of obtaining additional financial assistance
and/or donations.

I hereby declare that I have read and understood the contents of this form and have freely and voluntarily
executed this Employee Consent Form.

IN WITNESS WHEREOF, I/WE have signed this form this _______________ at Pasig City, Metro Manila,
Philippines.

________________________________
(Employee-signature overprinted name)

Conformity:

_________________________________
(Dependent-Relative-signature overprinted name)