CONSENT ON DATA SHARING

(Principal - For Corporate Account)

In relation to my healthcare membership with MediCard, the healthcare provider engaged by my Company,
Enter Company Name (company name);

I, Enter Name of Data Subject (Principal), of legal age, hereby grant my consent to MediCard to collect,
process, transfer or share my personal and health information (including those of my minor or
incapacitated dependent member/s specified hereunder, should there be any), whether such information is
existing or accumulating, with my Company and its agents or brokers, and with MediCard’s officers,
directors, employees, agents, consultants, contractors, representatives, and recognized service providers
which include MediCard’s accredited hospitals/clinics, physicians, diagnostic service centers, and other
allied health professionals involved in my or my dependent/s treatment or care, which will be necessary in
the assessment of my/our health care coverage, my/our treatment or administering of my/our claims;

I understand that in exceptional emergency situations, and in accordance with medical confidentiality
guidelines and relevant laws, MediCard and its recognized service providers may be required to disclose
such information to a relative, family member or other third party who happened to be my or my
dependent/s companion at the time of availing the healthcare services;

I am aware that I (and my minor or incapacitated dependent member/s, if applicable) am/are afforded with
certain rights and protection as a Data Subject in a separate Data Sharing Agreement executed by
MediCard and my Company, in accordance with the Data Protection Act of the Philippines and that I can
access the said Agreement at anytime through my Company or email request to
privacy@medicardphils.com;

Indicated below are the names of my minor or incapacitated dependent member/s that I will represent for
the purpose of this Consent and my relationship with them: (if applicable).
Name Relationship

I hereby hold MediCard free and harmless from any and all actions, claims, or liabilities which may arise as a
result of, or in connection with, executing this consent for and on behalf of my dependents by reason of
their incapacity to sign.
I hereby warrant that my consent to share personal information is entirely voluntary and I understand that
upon withdrawing this Consent at any time, I cannot compel MediCard or any of its network to deliver the
healthcare services to me or my dependent member/s covered by this Consent, thereby waiving my (and
my minor or incapacitated dependent member/s) entitlement to the benefits of MediCard;

I further  agree /  disagree (please tick the box) to receive promotional information from MediCard
about its products, services, or perks which may be of interest or benefit to me.

Enter Name of Data Subject (Principal)

[Signature of Data Subject over Printed Name]
Date: