8/18/2019 20140929 Photo Consent Form

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teamphilhealth

 Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre Building, 709 Shaw Boulevard, Pasig CityHealthline 441-7444 wwwphilhealthgovph 

CONSENT TO PUBLICATION OF INFORMATION

Name of Person Described in Article or Shown in Photograph: __________________________________________ 

I, _______________________________________________________give my consent for this information about!AS" NA#$, %I&S" NA#$, #IDD!$ NA#$

#yself'my child or ward'my relative to appear in full or in part in publications and products published byPhil(ealth in the future)

I also allow my child or ward'my relative*s image or video footage to be used in Phil(ealth*s advertising or pac+aging reuirements, as long as the usage is within the proper conte-t)

I understand that I can only revo+e my consent at any time before publication, but once the information hasbeen committed to print, it will no longer possible for me to revo+e this consent,

.ith this consent %orm, I free Phil(ealth from any liabilities that may arise from the publication of the imageor video footage)

Name and Signature __________________________________________ 

Date Signed _________________________________________________ 

&elationship if applicable/______________________________________ 

______________________________________ ____________________________________  WITNESS WITNESS

 

www!a"e#oo$"om%PhilHealth in!o&philhealthgovph

http://www.philhealth.gov.ph/http://www.philhealth.gov.ph/