By signing below, I authorize the Pharmacy operating under the brand “Medcare” within Aster DM Healthcare and their physicians, consultants, Pharmacists, nurses, other medical and non-medical staff, other employees (collectively the “Authorized Persons”) to authorized Persons, I undertake to inform authorized persons about all facts that pertains to my health and previous medical history/allergies/specific conditions/ disabilities irrespective of its relevance to the medicines prescribed by the treating Doctor. I acknowledge the fact that in case any of my disclosures are found to be untrue or incomplete, neither the Pharmacy nor the authorized Persons would be responsible for any consequences thereof. I hereby authorize and direct my insurance carrier and/or health care plan to make payment to Hospital Pharmacy for covered items and hereby assign to Pharmacy any and all rights, title and interest. I understand that I am financially responsible to the Pharmacy for all charges, including those not paid by insurers as specified in my Insurance Policy, incurred by me or in my behalf.

I hereby authorize and direct the clinic, and/or authorized Persons, to provide copies of all my medical records to government agencies, insurance companies, my family and relatives and others who are financially liable for my medical care, all information needed to substantiate payment for medical care.

I understand that Aster DM Healthcare will collect and store information relevant to my health together with other information for the purposes of insurance, administration and financial matters, including personal contact details (Personal Information). I consent to Aster DM Healthcare using the Personal Information, and sharing the same (limited to the extent necessary) for legitimate purposes, and to meet statutory obligations, including:
Sharing Personal Information with:
(a) Other healthcare providers for the purposes of patient care;
(b) My insurer, other third-party payers, agents and/or consultants for the purpose of reviewing, investigating, or processing any relevant claims for reimbursement and related matters; and
(c) DHA/MOH government Health authority in accordance with statutory obligations.

I also consent to Aster DM Healthcare to de-personalizing the Personal Information and sharing the same in a non- identifiable data format for the purposes of:
(a) education; (b) research; (c) assessing Aster DM Healthcare quality standards and clinical performance; and (d) internal business processes.

I have read or have been read to in a language I can understand, and I completely understood the general consent and authorizations stated hereinabove, accept the above terms and conditions and agree to abide by said requirements herewith. I have read the details on my/the patient’s prescription form and confirm that they are correct. I understand that my consent will remain in effect unless otherwise I explicitly stated. The word “I” mentioned in this Consent Form shall mean and include the patient or patient’s representative or legal guardian, as applicable and signed herein.