Patient Information Consent Form

Data Collection by City Life Polyclinic and Diagnostic Centre:City Life Polyclinic and Diagnostic Centre shall collect and process the following information from me:

• Contact information: Name, Address, Contact details, Email ID, Phone Number;
• Demographic information: Gender, Age, Date of Birth;
• Other information that I provide to CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE or is generated while availing services or interacting with CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE employees, doctors, technicians, consultants, etc.;
• Health information such as my medical records and history provided by me or generated by CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE in the course of my availing of any services from CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE;
• Information regarding my physical, physiological and mental health provided by me or generated on availing any services from CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE, etc.;
• Financial information (payment/billing information) that I provide for availing services from CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE; and
• Any other information relating to the above which I may have shared with CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE prior to the date of this consent form for availing any services.

Purpose of Collection: I understand that CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE may use the information mentioned above to provide me with services, or use it for other purposes, some of which are below:

• Registration to receive services, identification, communication, information on new services and offers, taking feedback, help and complaint resolution, other customer care related activities or issues relating to the use of my services;
• Creation and maintenance of electronic health records for use by CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE to provide relevant services;
• Customising suggestions for appropriate medical services offered by CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE;
• Research for the development and improvement of our services;
• Disclosure as required to government authorities in compliance with applicable law;
• Investigating, and resolving any disputes or grievances; and
• Any purpose(s) required by applicable law.

Disclosure and Transfer of Personal Information

• For the above mentioned purposes, and to the extent permitted by applicable law, CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE may share, disclose and in some cases transfer all or any information referred to above, to such entities as required to provide services to me, or for compliance with applicable laws. I understand that these entities include but are not restricted to CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE doctors, third party service providers to CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE, and law enforcement agencies. For these purposes, I consent to CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE transferring my personal information to entities that may be located outside India.
• I understand that in the event of a merger, reorganization, acquisition, joint venture, assignment, spin-off, transfer, asset sale, or sale or disposition of all or any portion of the CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE business, including in connection with any bankruptcy or similar proceedings, CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE may transfer any and all personal information to the relevant third party with the same rights of access and use.

Retention of Personal Information

• CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE will keep any information collected from me for as long as necessary to provide me with services or as may be required under any law.
• CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE may retain information related to me if needed to prevent fraud or abuse or for other legitimate purposes. CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE may store my personal information in de-identified form for the purposes indicated in Section 2 above.

My Rights

• I understand that I have the right to access my personal information, and request updation, correction and deletion of such information, but not information processed in de-identified form, or any information which is retained by CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE to comply with applicable law.
• I understand that I am free to not share any health, financial or other information that I deem confidential. I understand that I may withdraw consent for CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE to use data that I have already provided to it. I understand that if I exercise these rights, CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE can limit or deny the provision of services for which it considers such information necessary.
• I understand that I may contact citylife.pdc15@gmail.com for any questions or for exercise of these rights and for any other grievances related to my personal information.

I hereby give my consent to CITY LIFE POLYCLINIC AND DIAGNOSTIC CENTRE to collect, use, store, share, and / or otherwise process my personal information in accordance with this consent form.