The Patient Declaration Form is a fundamental document used in Malaysian healthcare settings to establish clear understanding and consent between patients and healthcare providers. This document is required whenever a patient begins their interaction with a healthcare facility or before undergoing medical procedures. It complies with various Malaysian regulations, including the Private Healthcare Facilities and Services Act 1998 and the Personal Data Protection Act 2010. The form typically includes patient identification, consent for treatment, financial responsibility acknowledgment, and privacy notices. It serves multiple purposes: documenting informed consent, establishing financial responsibility, protecting patient privacy rights, and creating a legal record of the patient's acknowledgments and agreements.
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1. Patient Information: Basic personal details including name, IC/passport number, address, and contact information
2. Healthcare Provider Details: Name and details of the healthcare facility/provider
3. General Consent for Treatment: Standard declaration of consent for medical examination, treatment, and procedures
4. Financial Responsibility: Declaration of understanding regarding payment obligations and billing procedures
5. Privacy Notice: Acknowledgment of how personal and medical information will be used and protected
6. Certification and Signature: Patient's (or legal representative's) confirmation that all information provided is true and consent is given voluntarily
1. Emergency Contact Authorization: Used when patient wants to authorize specific individuals to receive medical information or make decisions
2. Language Certification: Required when the form is explained in a language other than the written form
3. Clinical Photography Consent: Needed when the facility requires consent for medical photography for treatment or teaching purposes
4. Religious/Cultural Preferences: Include when facility needs to document specific religious or cultural considerations
5. Research Participation: Used when the facility conducts medical research and needs patient consent for participation or data use
1. Schedule A - Specific Procedures Consent: Detailed list of specific procedures the patient is consenting to
2. Schedule B - Fee Schedule: Breakdown of standard fees and charges that may be applicable
3. Appendix 1 - Patient Rights and Responsibilities: Detailed explanation of patient rights and responsibilities under Malaysian law
4. Appendix 2 - Privacy Policy: Detailed privacy policy and data protection procedures in compliance with PDPA 2010
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