With my signature below, I release the Company, its employees, subcontractors, or consultants and/or any agent thereof (hereinafter: "the Applicants") any duty to maintain medical confidentiality regarding my health condition, my medical history and/or my illnesses, and waive this confidentiality towards the Applicants. I confirm that I will not have any claim or demand of any kind against the Applicants pertaining to the above, including claims under the Patient's Rights Law regarding medical confidentiality, and/or any other law.
I acknowledge that providing my details is subject to my consent and is not required under any legal duty. I hereby grant my advance consent to provision of the services by the Company, to consultations and conversations that the Company (or any agent thereof) shall have with various parties who are, directly or indirectly, connected to provision of the services to me.
I know that the information will be saved in the Company's databases. I hereby give permission to the Applicants to deliver to medical entities in Israel and/or abroad and/or to any person or entity directly or indirectly related to the provision of services to me (including subcontractors, consultants, and Company employees) any information pertaining to me that is in the possession of the Company. I release and exempt the authorized persons from the obligation to maintain medical confidentiality with regard to the information, and I will not have any claim or demand of any kind against them in connection with the delivery of the information as stated above, including claims under the Privacy Protection Law, 5741-1981 and/or the Patient's Rights Law, 5741-1981 or the EU’ General Data Protection Regulation (GDPR) regarding privacy or medical confidentiality and/or any other law.
If the Company or its enterprise are sold or a merger with another company takes place ("New Company") in the future, with my signature below, I hereby authorize the Company in advance to transfer the information about me to the New Company in order to continue providing the services according to this agreement.
Also, I hereby give permission to any physician, medical worker, medical institution, and/or mental health center, as well as the HMOs (hereinafter: "the Service Providers), to provide the Company and/or any agent thereof with all the information in their possession about my state of health without exception, either in writing or orally, and in the manner required by the Company (or any agent thereof).
I release the service providers from the obligation to maintain medical confidentiality regarding my health condition and/or rehabilitation and/or illness mentioned above and waive this confidentiality in favor of the Company. I confirm that I will not have any claim or demand of any kind against them in connection with the said confidentiality waiver. My request is valid also according to the Privacy Protection Law, 5741-1981, and it applies to any medical or other information found in the databases of all the institutions and persons subscribed to the Service Providers listed above.
Further to the informed consent form and waiver of medical confidentiality that I signed towards you, I, the undersigned, hereby give permission to and request the Company to provide the persons listed in the table below with the findings report and any additional requested information pertaining to me.
Any information that is in the Company's possession regarding me, including information pertaining to my health condition and/or medical history and/or any illness that I have had in the past and/or from which I am currently suffering and/or about developments that will apply to my health condition in the future, including information about medical treatments I am undergoing.
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