International SOS [ PayPal Alabang]

[18F Axis One Building, Filinvest Ave. Alabang Muntinlupa City]

Clinic Tel: [249-2805]
Email: [mnl-clinic@paypal.onmicrosoft.com]

AUTHORISATION FOR RELEASE OF MEDICAL INFORMATION AC/CLINIC

PATIENT INFORMATION

Print Name: Micaela Angela Padua

First Last (surname)

Birth Date: May 20, 1995 Case #:

Day/Month/Year

TREATING PHYSICIAN IN COUNTRY OF ORIGIN: TREATING PHYSICIAN IN CURRENT LOCATION:

(please fill in name, address, e-mail address and telephone (please fill in name, address, e-mail address and telephone number)
number)

PURPOSE

This authorisation is to authorise the collection, release, use, storage, processing, amendment and transferring of medical, travel and other
personal data for the purpose(s) of providing assistance to me, including arranging medical treatment, assessing and paying and/or obtaining
payment for that treatment and assistance; running International SOS’ normal business and operations, and to comply with legal obligations and
respond to emergencies such as those relating to public health (“Data Collection Purposes”).

AUTHORISATION OF DISCLOSURE

I hereby authorise any organisation or person who has or may have information concerning me or my health to furnish International SOS
[PayPal Alabang], including the International SOS Group of Companies and/or their respective representatives and/or agents (“International
SOS”), who are acting on behalf of [PayPal Alabang], with:
(a) all relevant medical information pertaining to my medical history (including any condition for which medical advice or treatment was sought,
any form of consultation, investigation, prescription or treatment), it being understood that such disclosure must be compliant with applicable
local rules, if any (which may where applicable restrict release to medical professionals only);
(b) all relevant information pertaining to my employment history;
(c) a medical certificate completed by any health provider which International SOS may require; and
(d) travel information including all itineraries, ticket information and proof of payment documentation.
(collectively known as “Personal Data”)

I understand that information related to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), human
immunodeficiency virus (HIV), genetic test results, behavioral or mental health services, and treatment for alcohol and drug abuse, shall
not be disclosed unless: (i) required by law or (ii) I specifically authorise International SOS to make such disclosure by initialing here.

CONSENT TO USE MEDICAL INFORMATION

I consent to International SOS:

(a) Collecting by using telephone recordings, electronic, paper or other means, processing and using my Personal Data for the Data Collection
Purposes;
(b) Subject to local legal requirements (which may where applicable prevent disclosure to non-medical personnel and/or restrict release to
medical professionals only) disclosing my Personal Data to :
(i) entities of [PayPal Alabang], and/or of other International SOS entities or their respective representatives and/or agents, my personal
representatives or family member involved in my care;
(ii) the insurer or other entities which will be directly or indirectly responsible for or involved in payment of relevant medical and other
costs,
(c) Transferring my Personal Data outside [Philippines], to and from my doctors in my country of origin, and to and from the doctors where I
am currently being treated and to other territories that may not have the same level of personal data protection.

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International SOS [ PayPal Alabang]
[18F Axis One Building, Filinvest Ave. Alabang Muntinlupa City]
Clinic Tel: [249-2805]
Email: [mnl-clinic@paypal.onmicrosoft.com]

AGREED AND ACCEPTED

I understand and agree that :

(a) A copy of International SOS' Customer Personal Data Privacy Statement including information about my rights and instructions on how to fill
a complaint and access, correct, restrict access to or delete my Personal Data may be obtained by writing to: Director of Assistance,
International SOS or may be accessed through the International SOS website at www.internationalsos.com
(b) I have the right to refuse to sign this authorisation, and that if I do refuse, International SOS may be prevented from or limited in providing
the services described above and may not be able to assist me.
(c) This authorisation expires one (1) year from the date of signature below.
(d) If I sign this authorisation, I will have the right to withdraw/ revoke it at any time, except to the extent that action has been taken prior to
receipt of the withdrawal/ revocation. If I wish to withdraw/ revoke this authorisation, I can write to the Privacy Officer at
dpo@internationalsos.com.
(e) This authorisation and my Personal Data will be kept no longer than is desirable for the purposes they were collected and, subject to
applicable local law, will be destroyed in accordance with the periods set out in International SOS’ policy on data retention (published at
https://www.internationalsos.com/privacy).
(f) A copy, including photostat, electronic or fax copy of this authorisation, shall be considered as effective and valid as the original and I have
specifically authorised its use as such.

Micaela Angela Padua

Signature of Patient/Legal Representative/ Guardian Printed Name

October 19, 2022

Date Relationship with Patient

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