ean eaten Sevens) er eet mek Lvl? Tan Tock Seng hate ar fas Sy Sop so888 ae tala see rarast eee see ontcste CONSENT FOR RELEASE OF MEDICAL INFORMATION Instructions: 1 Tis frm must be tly completed and signed by he patient. the paint is below 21 years od, he foam should be signed by the patent's parent 12 ln patient is deceased or unable to give consent. consent is equed rm the appointed representative of he estate. Where appeale the "Concent fr release sf modcal normation by all chlren siblings” form must beled up. A copy of palents dean cence s ‘equed pont passed away ousice TSH ‘5. Photacops of rlovart documents (2. bith centile, marrage certcate and letters of adminsvaton) are to be stachod as poot of ‘elaiorsip spat spotcae, 44. Patent has to enclose a pratocay o own NAIC (ror & back vw) submit via al ax or ema 5. The completed foem musi be subted with payment a the fe. Cheque payment should be crossed and made payable 10 “Tan Tack Seng Hospital Pte tis 16. Thaveeaae ofthe mecca infrmaton|s subject oof approval 7 Kindy note at TTSH ls under anebgaton to gve fl and rank closure of ll materi ‘ato ited te he Human Immunodeicency wits (HI) and any ahr iectous Heath, te Heath Sconces Autor and any oer elvan! aos. EAs Guess! ‘Given Name (As in “NRIG/Passpon) ‘eating 1 your mecca condition, eluding requred Yo ba nctiied tothe Hsty of NAIC No: Maling Address: Period of Atlendance / Admission in TTSH: lincal Department: Gees \ 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 it form) is proved for completion [] 1 Ordinary Medical Report ($880.25) 1 Medical Certcate reprint ($810.70) 1 Specialist Medical Report ($$160.50) Lab resuit ($85.35 per ype) 1 Xray report (985.35) 1 Discharge Summary (No charge) 1 ay cb tims To request in person at Diagnostic] Others (Please speci: Radiology Department, Basement 1 (Fees payable depending on request type) Purpose of Request: Continuity of Gare 1 Leooal Proceedings insurance claims second Opinion insurance Application 1 others (Pease speci Remarks: Besides te media repo fe, | undertake to pay any sdditonal charges euch as xray and laboratory ivesigaton charges that may be cued ‘the preparation a he report. am azo aware that tere wl bea cancelation charge f 13 of he medial ep fee, sould ace To cancel ‘hs vequest, PREFERRED MODE OF COLLECTION twit personaly colette report once itis ready. Contact No 1 Send tomy maling address as stated above. A fe of $$10 for overseas postage is applicable) Send tothe acess ofthe company a person as stated above. (A lee of S$10 for overseas postage is applicable) 1 The report wil be collected by my representative. |am aware that an authorization llter with the representative's name & INRIC No and a copy of my NRIC have to be furnished upon collection, | nereby declare and conten that have been glen adequate explanation onthe conten of ths fom, which has been fly explained to me in [Rersby SCS Se conten Wt Nfanguage\ and have uly understood the same, The inormabon ian sbove ls sccurae and vue fhe isa of iy towadge, and tal the rent infomation Is requited for he sle purpose Sate above, | undertand That I may be lable for frosecution for making & fale decaraton. Further, | conti tat | shall ot hald Tan Tack Sang Hoeptal rary of ts empoyees, seven or penta responsible in any way whatsoever forthe fleas of the sld medal ration any pay by mei the event of any isa or damage ‘Stang desty orindrsty, a8 result orn connacton wih the rleace ot such conieraalmomation, By eeson ofthe eersad, undertake {ul responsblty en lal arse rom he eloase ofthe fequstenirmason, ‘Signature of Paiient / Next of Kin? Relationship to Patient Dale ‘Administrator of Estate * Delete whore appropriate His-AEP-01-0