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填寫完請按儲存按鈕以送出填寫資料/after filled the form please click the save button to save the answer

*為必填項目/* as Required items

*姓名/Name:

*身分證號/居留證號/Identifiction:

*國籍/nationality:

*性別/Sex:

血型/Blood Type:

*出生日期/Date of Birth:

身分/Identity:

婚姻狀況/Marriage:

職業/Occupation:

教育程度/Education:

*通訊地址/Mailing Address:

*連絡手機/Cellphone Number:

連絡電話/Telephone Number:

E-mail:

*緊急通知人/Next Of Kin:

*緊急通知人手機/Next Of Kin Cellphone Number:

緊急通知人電話/Next Of Kin Telephone Number:

*1: 同意/Agree 不同意/Disagree 醫院處理、利用本人留存病歷紀錄等相關通訊資料以寄發郵件、Email、簡訊、電話等方式通知衛教、健檢、病友會、醫訊、門診表、醫療新知、教學活動、關懷滿意度調查等，日後有反對意見可提出申請停止利用。
I hereby authorize the Hospital to process and utilize my medical record-related contact information to provide notifications via mail, SMS, or telephone. These notifications may include health education materials, health screenings, patient support groups,medical updates, clinic schedules, educational activities, and patient satisfaction surveys. Right to Opt-Out：I reserve the right to request the cessation of such data utilization at any time by submitting a formal application to the Hospital.

*2:就醫紀錄、結果資訊下載與跨院電子病歷調閱同意書
Consent for Accessing & Downloading Medical Records via NHI MediCloud and Inter-hospital EMR Systems

同意/Agree 不同意/Disagree 貴院於醫師診療病情、藥事人員調劑或用藥指導及其他醫事人員依其執業法規提供診療服務時，依本人醫療需要，於本人簽署本同意書日期起: (1)可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。 (2)透過跨院電子病歷系統下載調閱本人曾就診醫療院所之全部電子病歷資料。
前述資料，僅限本人於貴院就診，醫事人員為提供本人診療服務時，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。
For the purpose of clinical necessity, I hereby authorize the Hospital’s physicians, pharmacists, and other licensed healthcare professionals to access and download my medical data, effective from the date of this signature:
1. NHI MediCloud Access: To download medical history, clinical results, and billing data from the National Health Insurance (NHI) MediCloud System. This includes medication records, laboratory reports, diagnostic imaging, surgical history, and discharge summaries.
2. Inter-hospital EMR Exchange: To access and download my comprehensive Electronic Medical Records (EMR) from other healthcare institutions via the Inter-hospital Exchange System.

Data Privacy & Security：The aforementioned data shall be used exclusively for clinical diagnosis and treatment within this Hospital and shall not be used for any other purposes. All downloaded data will be deleted upon completion of the consultation, unless it is incorporated into my permanent medical record for ongoing care. In accordance with the Personal Data Protection Act, I retain the right to modify or revoke this consent at any time.

備註：一、立同意書人，由病人親自簽具；如病人為未成年人或無行為能力人者，其同意書之簽具，得類推適用醫療法第74條規定，得經其法定代理人、配偶、親屬或關係人之同意。二、立同意書人非病人本人者，「與病人之關係欄」應予填載與病人之關係。三、健保醫療資訊雲端查詢系統如有增修查詢及下載項目，以健保署公告為基準。
Notes
1.Signatory Requirements: This form must be signed by the patient. For minors or patients lacking legal capacity, the signature may be provided by a legal representative, spouse, or relative, pursuant to Article 74 of the Medical Care Act.
2.Proxy Signatures: If the signatory is not the patient, the "Relationship to Patient" field must be completed.
3.Regulatory Updates:Any future updates to the searchable or downloadable items within the NHI MediCloud System shall be governed by official NHI Administration (NHIA) announcements.

高雄榮民總醫院初診資料填寫