Consent For Release Of Medical Information

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Health Information Services (MRO)
Tan Tock Seng Hospital Atrium Block, Level 2
11 Jalan Tan Tock Seng Singapore 308433
Tel: 6357 8448
Fax: 6357 8449
Email: .sg
CONSENT FOR RELEASE OF MEDICAL INFORMATION
Instructions:
1.
This form must be fully completed and signed by the patient. If the patient is below 21 years old, the form should be signed by the patient’s
parent.
2.
If the patient is deceased or unable to give consent, consent is required from the appointed representative of the estate. Where applicable,
the “Consent for release of medical information by all children / siblings” form must be filled up. A copy of patient’s death certificate is
required if patient passed away outside TTSH.
3.
Photocopies of relevant documents (e.g. birth certificate, marriage certificate and letters of administration) are to be attached as proof of
relationship to patient if applicable.
4.
Patient has to enclose a photocopy of own NRIC (front & back view) if submitting via mail, fax or email.
5.
The completed form must be submitted with payment of the fee. Cheque payment should be crossed and made payable to “Tan Tock Seng
Hospital Pte Ltd”.
6.
The release of the medical information is subject to official approval.
7.
Kindly note that TTSH is under an obligation to give full and frank disclosure of all material facts relating to your medical condition, including
but not limited to, the Human Immunodeficiency virus (HIV) and any other infectious diseases required to be notified to the Ministry of
Health, the Health Sciences Authority and any other relevant authorities.
PATIENT’S PARTICULARS
Given Name (As in *NRIC/Passport): ______________________________________________________________________
NRIC No: ____________________________________________________________________________________________
Mailing Address: ______________________________________________________________________________________
Period of Attendance / Admission in TTSH: ______________________ Clinical Department: __________________________
REQUEST
I, ______________________________________________________ of NRIC No _________________________________
hereby authorize TAN TOCK SENG HOSPITAL to furnish and release below stated
TO: Name of Company or Person: ______________________________________________________________________
Address of Company or Person: ____________________________________________________________________
Type of Request:
[Please indicate if form(s) is provided for completion
]
Ordinary Medical Report (S$80.25)
Medical Certificate reprint (S$10.70)
Specialist Medical Report (S$160.50)
Lab result (S$5.35 per type)
X-ray report (S$5.35)
Discharge Summary (No charge)
X-ray CD/ films - To request in person at Diagnostic
Others (Please specify): _______________________
Radiology Department, Basement 1 (Fees payable depending on request type)
Purpose of Request:
Continuity of Care
Legal Proceedings
Insurance Claims
Second Opinion
Insurance Application
Others (Please specify): ________________________
Remarks: ___________________________________________________________________________________________
Besides the medical report fee, I undertake to pay any additional charges such as x-ray and laboratory investigation charges that may be incurred
in the preparation of the report. I am also aware that there will be a cancellation charge of 1/3 of the medical report fee, should I decide to cancel
this request.
PREFERRED MODE OF COLLECTION
I will personally collect the report once it is ready. Contact No: ______________________________________
Send to my mailing address as stated above. (A fee of S$10 for overseas postage is applicable)
Send to the address of the company or person as stated above. (A fee of S$10 for overseas postage is applicable)
The report will be collected by my representative. I am aware that an authorization letter with the representative’s name &
NRIC No and a copy of my NRIC have to be furnished upon collection.
I hereby declare and confirm that I have been given adequate explanation on the contents of this form, which has been fully explained to me in
_____________________________ (language), and have fully understood the same. The information given above is accurate and true to the
best of my knowledge, and that the requisite information is required for the sole purpose stated above. I understand that I may be liable for
prosecution for making a false declaration. Further, I confirm that I shall not hold Tan Tock Seng Hospital or any of its employees, servants or
agents responsible in any way whatsoever for the release of the said medical information to any party by me in the event of any loss or damage
arising directly or
indirectly,
as a result or in connection with the release of such confidential information. By reason of the aforesaid, I undertake
full responsibility and liability arising from the release of the requisite information.
______________________________
______________________________
______________________________
Signature of *Patient / Next of Kin /
Relationship to Patient
Date
Administrator of Estate
* Delete where appropriate
HIS-REP-01-03

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