Register New Patient

I voluntarily consent to care and treatment at [Dialysis Clinic Name], which may include examinations, tests, medications, and procedures. I understand that:

1. I am aware that I suffer from kidney failure, a condition in which my kidneys are not able to perform their normal function as stated below but not limited to the following:
• a. Removal of wastes/impurities/toxins from my blood.
• b. Regulation of water, electrolyte and acid – base balance.
2. The procedure necessary to treat my condition has been explained to me by my attending physician and I understand the nature of the procedure, that is, hemodialysis is a renal replacement therapy that involves the passage of blood from my circulatory system to the dialysis machine where it passes through a device called dialyzer (external artificial kidney which acts to remove impurities and excess fluid).
3. I am aware of certain risks and consequences associated with the dialysis procedure which include the following, among others;
• a. There is a possibility of a decrease in my blood pressure, cramps, headache, irregular heartbeats and mild confusion resulting from fluid removal, chemical shift and imbalance within my system, reaction to medications or blood transfusion which may have adverse results ranging from mild to fatal shock (rarely) or cardiac arrest.
• b. There is a possibility of excess bleeding occurring anywhere in my body as a result of clotting problems, blood leaks, vascular access problems, or externally-related disconnection of bloodlines.
• c. There is a possibility of infectious hazards being introduced including viral hepatitis, infection at the puncture site or shunt or infected central venous catheter.
• d. There is a possibility of blood contamination with various microorganisms which may result in bloodstream infection or sepsis.
• e. There is a potential risk for air embolism where air enters the blood stream resulting in severe complication like paralysis, more so, cardio-respiratory arrest.
4. I am aware that my dialyzer is being reprocessed up to 10 times maximum usage unless it fails or if ordered otherwise by my attending nephrologist or if I request for a change of dialyzer.
5. I must follow and respect the General Guidelines for Hemodialysis Treatment as stated by the policy of the Center.

This agreement form is intended to verify that you have received adequate information verbally and in writing, including PhilHealth's guidelines for availing of the benefits package for hemodialysis (HD). The HD facility should clearly explain to you the significance of the contents of this Agreement Form in the language that you understand and will furnish you with a copy of the form for each unique treatment session.

1. I have been fully informed by Northern Renal Health Inc. representative of the PhilHealth policies on availing of the benefits package for HD.
2. I understand that PhilHealth covers up to 156 treatment sessions per calendar year for patients with chronic kidney disease stage 5 (CKD5).
3. I understand that the HD package provides coverage for the minimum standards required by CKD5 patients, as enumerated in the applicable PhilHealth policy.
4. I understand that the package rate for HD is PHP 6,350 per treatment session. This includes the fees for the health facility and the professional.
5. I understand that the provision of the services depends on the patient's status; therefore, I will receive the following services that are clinically indicated and necessary for my treatment session:
   • Drug/Medicine
   • Laboratory Tests
   • Supplies
   • Administrative and Other Fess
6. I understand that I may be charged a copayment for the following items, amenities, additional services, and premium services that are not covered by PhilHealth

This form is used to obtain informed consent from patients regarding the collection, use, storage, and sharing of their personal and medical information, in compliance with the Data Privacy Act of 2012 (R.A. 10173).

I hereby give my consent to Northern Renal Health Dialysis Center to collect, use, store, and process my personal, sensitive, and medical information for the purpose of providing dialysis treatment and related healthcare services. I understand and agree to the following:

1. Data Collection: NRHDC will collect my personal and medical data including, but not limited to:
   • Personal identification information (name, birth date, age, sex, address, contact number, marital status, emergency contact)
   • Government identification details (PhilHealth number, SSS number, TIN, valid ID numbers)
   • Medical information (diagnosis, treatment plans, lab results, dialysis prescriptions, vital signs, treatment history, allergies, comorbidities)
   • Financial and billing information (insurance/PhilHealth claims, billing records, payment history)
2. Purpose of Data Use: My data will be used solely for:
   • Delivery of dialysis and medical care
   • Documentation and medical records management
   • Processing of PhilHealth claims and billing
   • Quality assurance, internal audit, and regulatory compliance
   • Coordination and referrals to other healthcare facilities when necessary
3. Data Storage and Protection: NRHDC will store my data in secure systems and physical files, accessible only to authorized personnel. Appropriate organizational, physical, and technical security measures are in place to prevent unauthorized access, disclosure, alteration, or destruction of my data.
4. Data Sharing and Disclosure: My data may be shared only with:
   • Attending physicians and healthcare staff directly involved in my care
   • PhilHealth and government regulatory agencies as required by law
   • Other healthcare institutions in case of referral or transfer (with my consent) NRHDC will not disclose my data to third parties without my written consent unless required or permitted by law.
5. Rights of the Data Subject: I understand that I have the right to:
   • Access, review, and correct my personal data
   • Withdraw my consent anytime (subject to legal or contractual restrictions)
   • File a complaint with the National Privacy Commission in case of data breach or unauthorized use
6. Data Retention: My data will be retained for as long as necessary to fulfill the purposes stated above, or as required by law and regulatory agencies.

By signing this form, I acknowledge that I have read, understood, and voluntarily agree to the terms stated above.