Consent For Release Of Medical Information (Medical Records) printable pdf download

Health

Information

Services

(MRO)

Tan Tock Seng Hospital Podium Block

Level 2, 11 Jalan Tan Tock Seng

Singapore 308433

Tel: 6357 8448

Fax: 6357 8449

CONSENT FOR RELEASE OF MEDICAL INFORMATION (MEDICAL RECORDS)

Notes:

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.

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.

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.

Patient has to enclose a photocopy of own NRIC (front & back view) if submitting via mail and fax.

Completed form must be submitted with appropriate fee and a fee of $10 for overseas postage is applicable.

The release of the medical information is subject to official approval and the requester would be notified about

the status and the fee incurred.

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 the following medical records

TO: Name of Company or Person: ___________________________________________________________________

Address of Company or Person: _________________________________________________________________

Type of Medical Records:

Original X-rays

Duplicate X-rays

X-ray Reports

Lab Results

Discharge Summary

Others (Please specify): _____________________________________________

Purpose:

Continuity of Care

Legal Proceedings

Second Opinion

Insurance Claims

Others (Please specify): _______________________________

Remarks: ______________________________________________________________________________________

PREFERRED MODE OF COLLECTION

I will personally collect the records once it is ready. Contact No: _____________________________________

Send to my mailing address as stated above. (Not applicable for X-ray films)

Send to the address of the company or person as stated above. (Not applicable for X-ray films)

The records 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 has to be furnished upon collection.

I hereby declare and confirm that the information given above is accurate and true to the best of my knowledge and belief, and that the requisite information / Medical

Record is required for the 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 the

Hospital or any of its employees, servants or agents responsible in any way whatsoever for the release of the said information / Medical Record 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 confidentiality information / Medical Record. By reason of the

aforesaid, I undertake full responsibility and liability arising from the release of the requisite Information / Medical Record.

Relationship: _______________________

_______________________________________________

Signature of *Patient / Next of Kin / Administrator of Estate

Date:______________________________

* Delete where appropriate

HIS-REQ-04-04