L2
HMO Consent Form
1.
I, _____________________________________ and my dependents, hereby give my consent to ADEC
Innovations and Asalus Corporation (Intellicare) or the Company’s HMO service provider, to collect,
process, examine, store copies and share my personal data, including my name, address, birthday,
birthplace, gender, marital status, education, employment, skills, information pertaining to my health,
height, weight, government-issued information and other records, contact information, privileged medical
information, medical records, including similar information about my parents, spouse, children, and/or
siblings and/or my dependents (herein referred to collectively as “personal data”);
2.
I hereby give authorization to use the subject personal data for any or all of the following purposes:
a. To create, maintain, and submit my records and information about my and my dependents’ health;
b. To create, maintain, and share my personal data and those of my dependents, in favor of the
Company’s HMO Service Provider, Intellicare, subject to the terms and conditions of a valid Data Sharing
Agreement between said Company’s HMO Service Provider, Intellicare and the Company for the
protection of personal information and respect for, and provision of, my rights as data subject, and in
connection with the following specific purposes:
i.
ii.
iii.
administration of Health Insurance benefits for the employees and dependents;
conduct of annual physical examination;
assessment and examination by Intellicare’s affiliated or accredited hospital clinics,
medical providers, physicians and other medical professionals
iv. Profiling or historical statistical analysis, providing advice or information which Intellicare and
its Representatives believe may be of interest to me or the Company.
v.
To effectively administer or manage my HMO membership with Intellicare and enhance
Intellicare’s services to me and the Company;
vi. For any purposes necessary and incidental to the performance of the services by Intellicare to the
Company.
3.
I agree and understand that the Company and Intellicare will give me access to all personal and sensitive
personal information about myself, and that I may at any time request the Company and Intellicare to
block, remove, correct, or update any information as may be necessary. I further agree and understand
that it is my obligation to give the correct and updated information to the Company and/or Intellicare
without need of demand;
4.
I further agree and understand that I may withdraw at any time, in whole or in part, the consent I am giving
under this Consent Form by contacting the head of Compensation and Benefits under Human Resources
Department. I understand, however, that the withdrawal of consent to collect, process, use, share, or store
any of my personal information may cause unnecessary delay or impairment in the delivery of the services
by Intellicare and/or its affiliated medical services provider. I hold the Company and Intellicare free and
harmless for any damage, cost, or expense that I may incur in the event that my withdrawal of consent
results in the delay or failure of the Company and/or Intellicare to deliver relevant services in connection
with my HMO or medical benefits;
5.
I also agree and understand that the Company has the option to refuse to block or remove the personal
information I provided in accordance with this Consent Form, if the collection, storage, and processing of
any particular personal information or set of personal information is mandated by law or regulation, is
indispensable to the processing and/or maintenance of my membership to the Company’s HMO Provider
and related benefits, or is necessary to handle contingencies and emergency situations affecting my
health or poses danger to my life or physical well-being.
6.
I am aware that I have the right of recourse against the Company and Intellicare and may be entitled to
damages should either or both violate the terms and conditions of this Consent Form.
I affirm that I am giving this consent freely and voluntarily in connection with my membership or enrolment in the
Company’s HMO Service Provider. I also affirm that I have been duly authorized by my dependent/s to sign and
execute this Consent Form for and in (his/her/their) behalf as if the same were personally done by
(him/her/them).
Name of Employee
Signature
Name of Dependents:
Date:________________
I-045031.01
10/09/19