PDF《ST. TERESA'S HOSPITAL》

(c) 进一步资料(如有需要)以便院方翻查有关记录(such further information as may be reasonably required for the Hospital to locate the requested records);

and (d) 缴交应付费用 (payment of a fee charged). Part F. 签署 Signature 本人谨此声明在本申请表格内所提供的资料准确无讹.本人已阅读本申请表之附件『病人申请医疗资料 须知』及明白其内容. I declare that the information given in this Application Form is true and accurate. I have read and understand the contents of the Notes of Application/Information attached to this Application Form. 日期(Date)签署(Signature) (病人/代表病人之有关人士) (Patient/ Relevant Person on behalf of the patient) 只供有关部门填写 (For Office Use Only) ? Applicant'

s ID checked ? Relationship/ authority checked Charges:$……………STR…………………Dr.$……………Status: Paid / Unpaid Waive by………… Notice Applicant Date:Checked by: Part D. 申请项目 The Requested Records [可选多项] ? 医疗报告 (Medical Report) ? 保险公司问卷 (Insurance Questionnaire /APS) ? 医生信/补充资料 (Doctor Letter / Supplementary Information) ** 请注明医生 (Please specify Doctor) ? 物理治疗师报告 (Physiotherapist Report)

4 Medical Records Department/2017 申请医疗报告须知 1. 申请人必须以中文或英文填写本表格.如本表格并非以中文或英文填写,本院有权拒 绝处理有关申请. 2. 申请人必须完成本表格,并将表格正本及所需的证明文件亲身递交或邮寄到本院之医 疗记录室. 3. 请必须於表格内清楚地描述申请人所需的记录.假如申请人无法提供本院需要用作翻 查医疗记录的有关资料,本院将保留拒绝接受其申请的权利.如申请人因任何理由故 意地提供虚假或具误导性的资料,申请人将可能受到刑事检控. 4. 如申请人未能提供本院要求的证明文件或所需文件,申请人的查阅资料申请可能会被 拒绝. 5. 就处理申请人的要求,本院将收取有关费用.假若本院未能收到相关费用前,申请人 提出的申请将可能不获处理. 6. 本院只负责处理驻院医生填写医疗报告.若非驻院医生,请自行与医生联络.不便之 处,敬请见谅. 7. 如申请人在本院已处理其申请的医疗报告后才撤销申请,本院可能不会发还有关费用. 8. 若申请人非病者本人,申请人递交申请表时必须提交 Part E 和Part B (ii) 内提及的所需 证明文件. 9. 在任何情况下,本院在取得病人授权或核实第三方申请人所提交的相关支持文件(Part B (ii) 和/或Part E ) 前均不会向第三方发放任何有关病人的医疗报告. 10. 所有医疗报告均以英文签发,本院不会提供翻译服务. 11. 根愀鄹鋈俗柿纤揭ㄔ惫鸬

486 章个人资料(私隐)条例的指引,本院会在收 到有关申请后的

40 天内处理. 12. 如有任何查询,请与本院之医疗记录室联络: 直线

电话: (852)

2200 3434 内线 697/ (852)

2200 3179 传真: (852)

2200 3199 电邮: [email protected] 办公时间: 星期一至五 早上八时至下午八时 星期六 、日及公众假期 早上八时至下午四时 *除非得到有关人士的许可,否则於申请表上所提供的个人资料仅供本院处理有关申请之用. *本院会随时修订上述资料, 不作另行通知.

5 Medical Records Department/2017 NOTES OF APPLICATION OF MEDICAL REPORT 1. Please complete this Form in Chinese or in English. The hospital may refuse to comply with your request if your request is not made in either language. 2. Applicant must complete this Form and submit the original to Medical Record Office together with supporting documentation in person during opening hour or by mail. 3. It is important that you specify in this Form clearly and in detail the records that you request. The hospital may refuse to comply with your request if you have not supplied it with such information as it may reasonably require to locate the requested records. If you supply any false or misleading information in this Form for the purpose of having the Hospital comply with your request, you may be liable for committing an offence. 4. Failure to provide the Hospital with the requested identification or other supporting documentation may result in the data access request being refused. 5. The Hospital will charge a fee for complying with your request. Compliance with a data access request may be refused unless and until any such fee has been paid. 6. We regret that we would not handle medical report for patients under the care of our visiting doctors. Please contact the attending doctors directly. 7. Fees paid for medical reports may not be refunded if the application is withdrawn after the reports are prepared. 8. The applicant must provide identity document specified in Part E and supporting documentation in Part B (ii) of the Form if the application is made by another person other than the patient. 9. Under no circumstance will any records be released without prior consent from the patient or before the hospital has verified the identity of the person other than the patient making the request with all relevant supporting documentation in Part B(ii) and / or Part E of this Form 10. All medical reports are written in English. The hospital does not provide translation services. 11. Pursuant to the Personal Data (Privacy) Ordinance (Chapter 486) the hospital shall comply with a data access request not later than