DATA PRIVACY POLICY CONSENT STATEMENT

This consent is given as the basis of collecting, processing, storing, sharing and destroying all my personal information, disability-related documents, medical records and other pertinent data/files.

Instruction: Please put a check in the box if you agree on the Data Privacy Consent terms written below. All Boxes should be checked and will indicate your 100% willingness and understanding of the Data Processes involving your transaction with the Muntinlupa Persons with Disability Affairs Office (PDAO) in compliance to the Data Privacy Act of 2012 (RA 10173).

I accept that Muntinlupa PDAO holds my personal data (patient and guardian) and I hereby consent to their utilization, perusal, procedures and processing or any associated government / non-government entity they deem fit to be sharing my information for any purpose related to my personal benefit / welfare or the entirety of the Muntinlupa Disability Sector I am a part of. I am wilfully submitting all my documents and information to the lawful and ethical use of Muntinlupa PDAO. This involves all activities regarding data collection, data processing, data sharing, data / record safekeeping, data / record destruction and other related essential processes. I explicitly consent to Muntinlupa PDAO or any of their chosen associates / partners in processing any sensitive personal data relating to me; for example medical records, any statistic that I am a part of in their data, contact information, records handling and etc. I have read and fully understood the contents of this consent. I agree to all its contents regarding the use and handling of my personal information.

No, I do not give my consent

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Personal Information

* All Fields are required!

Last Name

First Name

Middle Name

Suffix

Birthdate

Sex

Civil Status

Blood Type

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Disability Information

* All Fields are required!

Type of Disability

Cause of Disability

Apparent Disability

Diagnosis

Name of Certifying Physician

Physician License Number

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Contact Information

* Fields are required!

House No. / Street / Address *

Barangay *

Landline

Mobile/ Cellphone No. *

Email Address *

Contact Person *

Contact No. *

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Other Information

* Fields are required!

Educational Attainment *

Status of Employment *

Category of Employment

Occupation *

Philhealth ID No. *

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Required Attachments

* All Fields are required! * File Size Limit : 5MB

Photo of Registrant (ID Photo)

Whole Body Picture

Valid ID Attachment

Certificate of Disability

Medical Certificate Attachment

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Application Summary

Please review your application and click CONFIRM to submit.

Personal Information

Last Name	First Name	Middle Name	Suffix
DELA CRUZ	JUAN	DE GUZMAN	N/A
Birthdate	Sex at Birth	Civil Status	Blood Type
8/20/2000	MALE	SINGLE	A+

Disability Information

Type of Disability	Cause of Disability	Apparent Disability
DEAF / HARD OF HEARING	CONGENITAL	NO
Description	Certifying Physician	Physician Lic. No.
LEFT EAR CANNOT HEAR	DR. SOMETHING COOL	123-45-76890

Contact Information

Address	Barangay
GREENHEIGHT SOMETHING LONG ADDRESS	POBLACION

Landline	Mobile No.	Email
n/a	09998887777	[email protected]
Contact Person	Contact No.
DR. SOMETHING COOL	09998887777

Other Information

Educational Attainment	Status of Employment	Category of Employment
NONE	UNEMPLOYED	--

Occupation	Philhealth ID No.
NONE	123-456-7890

Attachments

Photo of Registrant	Whole Body Picture	Valid ID

Certificate of Disability	Medical Certificate

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