- 本人因健康因素至部立雙和醫院診療，我了解診療之必要性，也了解醫院為教學醫院會有教學行為，我同意醫師及相關醫事人員給予之必要處置，也同意醫院以保護性之方式將姓名公佈於就診名單上。同時我了解就醫權利與合作義務，以及醫院對我的健康資訊會予以保護。
- 本人同意於臺北醫學大學‧部立雙和醫院就診，醫事人員為提供本人診療服務時，可事先自衛生福利部中央健康保險署依全民健康保險法相關規定建置之健保醫療資訊雲端查詢系統，下載本人就醫紀錄、就醫結果及醫療費用資料，包含用藥紀錄、檢查(驗)項目與結果報告、檢查(驗)影像檔、手術項目及出院病歷摘要等資料，依醫療需要查詢比對使用，不得將該項資料另移作其他目的使用，且本人完成看診後，即應將該下載資料刪除。但下載之資料，醫師及其他醫事人員因醫療需要，已列入病歷者，不在此限。本人依個人資料保護法第3條規定，保留隨時取消本同意書或變更本同意書內容之權利。
- 本人了解且同意在本表格中所填寫及就診相關資料， 貴院可將其作為臺北醫學大學體系內部管理、醫療參考、聯絡、整體資料分析統計、學術及研究之用；且了解 貴院依據醫療法與尊重病人隱私，對所有就診相關資料之內容負有保密之責，並對病人病歷善盡保管與保密之義務；任何個人資料，均不會轉讓、租借、出售給其它團體或個人；上列個人資料日後如有變更或錯誤，請向批掛人員提出更正或修改，以利資料正確。
- I, the undersigned, am seeking medical attention at TMU-Shuang Ho Hospital for health reasons. I understand the necessity of medical treatment, I understand that the hospital is a teaching hospital and will engage in teaching practices. I consent to receiving necessary medical treatment from doctors and associated staff, and to the hospital publishing my name on a list of patients in a secure manner. I understand my right to healthcare and my duty to cooperate. I also acknowledge that the hospital will safeguard my health information.
- I hereby authorize physicians, pharmacists, and other medical personnel at Taipei Medical University-Shuang Ho Hospital to access my medical information from the NHI MediCloud System, which has been established by the National Health Insurance Administration under the Ministry of Health and Welfare. In accordance with the provisions of the National Health Insurance Act, I hereby authorize physicians and other medical personnel to provide treatment, consultations, or any other necessary medical care for my condition, starting from the day this consent is signed. The medical information mentioned includes my visit records, result data, and medical expenditure claims. This also covers medication records, examination records and results, medical images and reports, surgery records, and discharge summary. Please note that this information is strictly confidential and should only be used for its intended purpose. At the end of my medical treatment, all downloaded information should be deleted, except for information that has been downloaded and included in the medical chart as necessary for medical care by physicians or other medical personnel. In accordance with Article 3 of the Personal Data Protection Act, I reserve the right to revoke or modify this consent at any time.
- I understand and agree that all information provided on this form will only be used for internal management, medical reference, contact, data analysis, statistics, academic, and research purposes at TMUH. Additionally, I understand that TMUH has a responsibility to maintain the confidentiality of my medical information, in accordance with the Medical Care Act and respect for patient privacy, and will not release it to any organization or individual. All personal information will not be transferred, leased, or sold to any organization or individual. If there are any changes or corrections needed for personal information in the future, I will notify the staff at the registration counter to ensure that all information is accurate.