PRIVACY NOTICE

Data Protection and Privacy Policy Statement

Dr.Lovie Hope Go-Chu and the staff of her clinic at the Makati Medical Center Room 215 are committed to the
protection of your personally identifiable information (personal data) and your privacy. This Data Protection
and Privacy Policy statement, prepared in accordance with the Data Privacy Act of 2012 (DPA), describes our
personal data protection practices being implemented to protect the personal data of our patients.

Occasionally, we may amend the content in this section to reflect changes in the Data Privacy Act of 2012 and
our personal data collection and use practices.

Information We Collect

As a patient of the clinic, we will be making a medical record with your health information, including the care
and treatment you receive. We collect personal data whenever you consult at the clinic in person, when you
call the clinic, or when you communicate with us through any other medium such as SMS, Viber, etc. Personal
data collected may include your name, contact information, history of your illness and other pertinent
information, diagnosis, and treatment information. It may also include Philippine Health Insurance
Corporation (Philhealth) numbers and information on your health plan.

Consent

By providing your personal data when you communicate with the staff of the clinic, you confirm your
agreement to the terms and conditions set forth in this Data Protection and Privacy Policy, and you have
explicitly authorized and consented to our processing of your Personal Data.

Protecting Your Personal Data

In order to protect your personal data collected and used in the clinic, we are committed to complying with
the provisions of the Data Privacy Act. We uphold your rights as a data subject. We have implemented
organizational, physical, and technical security measures to protect your personal data.

How We Use Your Information

We collect, use, and process your personal information primarily for your medical management. To respect
your privacy, we will try to limit the amount of information that we collect and use to that which is
necessary to accomplish the purposes provided below:

1. For treatment: Residents and other doctors involved in your care will have access to your
information. We may also release medical certificates or clinical abstracts upon your verbal or
written request.
2. Individuals involved in your care: With your permission, we may share medical information about
you with a family member or friend who is involved in your care. In cases where you are unable to
provide consent, we may use and disclose information about you if necessary to protect your life and
health.
3. To prevent a serious threat to health or safety: We may use and disclose certain information about
you when needed to prevent a serious threat to your health and safety or the health and safety of
others. However, any such disclosure will only be to someone able to help prevent the threat, and
only to the extent required by the situation.
4. Worker’s compensation: We may release medical information about you for worker’s compensation
or similar programs. These programs provide benefits for work-related injuries or illnesses.
5. For appointment reminders.

Patient’s Signature
 6. For payment: If you intend to use your health plan under a Health Maintenance Organization (HMO)
or any other third-party payer, we may use and disclose medical information about you to bill for the
treatment and services your receive.
7. For research: We generally ask for your consent before using your medical information or sharing it
with others for research purpose. Under limited circumstances, a research involving use of your
medical records may be possible without your authorization, if the research is approved through an
independent review process to ensure anonymization of your health record and minimal risk to your
privacy.
8. For education and training:With your permission, we may share information with other medical
personnel and specialty societies for educational purposes. During such instances, the clinic will
limit the disclosure of your information only to the extent necessary for education and training
purpose, which shall not include your name or other identifying data.
9. Public health activities and other uses or disclosures required by law: We may disclose medical
information about you for public health activities such as reporting requirements of the Department
of Health, or other disclosures required or authorized by law.
10. Medico-legal cases: We may release medical information if asked to do so by a court of law in
response to a court order, subpoena, summons, or similar process.
11. Other uses of medical information: Other uses and disclosures of medical information not covered
by this Notice will be made only with your written authorization.

Sharing Your Personal Data

The Clinic will notshare your personal data with anyone without your expressed verbal and/or written
consent. Exceptions include emergency situations, medico-legal cases, and mandatory reporting by the law.

PATIENT CONSENT

By signing this form, I hereby confirm that I have read and agree with the above Privacy Notice.

__________________________________________________________ _________________________________________
Patient’s Signature above printed name OR Date (MMM/DD/YYYY) and Time (0000H)
Patient’s Representative above printed name (please indicate)

References:
“Data Privacy Act (Guide for MDs),” prepared by Ivy D. Patdu, March 18, 2018
“Data Protection and Privacy Policy Statement,” prepared by Dr. Pia Sia

Patient’s Signature
Patient’s Signature