• simplicity; less legalese; easily translatable to local language
  • help make privacy conversation happen between providers (doctor/hospital) and clients/patients, making the process more educational rather than adversarial
  • alert patients and healthcare professionals on privacy rules and processes for mutual recognition of certain duties, responsibilities & rights
  • forms and other mechanisms (enlightened care, rights education) to work together
  • minimize paper work and avoid potential confusion
  • Suggested statements to be incorporated into 2 forms: PATIENT ADMISSION & ADMITTING ORDER
  • Patient Admission Form: To be accomplished by patients/guardians/legal reps
  • Admitting Order: To be accomplished by Attending Physician

Hospital Facility, In-Patient

Draft for Patient Admission Form

Agreement and Consent

    I  __(patient’s name or legal guardian)_____ give permission to <name of hospital> or any health professional involved in my care delivery to gather and access health information about me that is relevant to my current treatment. Such health information will also be held and processed by this hospital, its health professionals, and the Philippine Health Information Exchange (PHIE) for continued medical care or for public health purposes. I cannot be denied medical care due to non-participation in PHIE.

	I understand that suitable safeguards have been put in place, so as to protect my privacy, welfare and other fundamental rights.

	<name of attending physician to filled out by hand writing> has explained to me this agreement and my hospital admission, and I consent to both.  I understand that this agreement only relates to the overall care delivery until such agreement is revoked by me. Specific medical procedures may require separate consent from me.

	Patient Name and Signature / Date

Draft for Admitting Order


  I have explained to <name of patient/family/guardian to be filled out by hand writing> the Agreement under Patient Admission Form, the nature of the patient’s condition as well as the necessity of the hospital admission. I have discussed the need for him to consent separately to medical procedures that may be required later.

   All questions were answered and the patient/family/guardian consents to the hospital admission and the collection and processing of the patient health information by this hospital, its health professionals, the Philippine Health Information Exchange (PHIE) and for public health purposes sanctioned by a duly constituted, independent Health Information Use and Safety Monitoring Board. I also explained that suitable safeguards (including, but not limited to, anonymization of personal identifiers) have been put in place, so as to protect the privacy, welfare and other fundamental rights of the patient.

   Attending Physician / Date

Hospital Facility, Out-Patient

See Also