Consent Form

We care about your privacy and the privacy of your family members. In line with the General Data Protection Regulation (GDPR), we need your consent to collect and process your health and other data. If you do not provide your explicit consent for the processing of your personal data as outlined below, we will not be able to handle your data, provide cashless access to treatment or process any claims that may be owed to you. For more information, please have a look at our privacy notice.

If you agree, your data will be processed for the following reasons and activities.

The table below needs to be completed only by those members under this policy who have not already provided consent before. Their consent will be valid for the entire duration of their policy unless they decide to change or revoke at any time.

A parent or guardian should complete the consent for any member that is under the age of 18.

I agree to the following:

  1. Permission to collect, store and use my health data: my data is being collected, stored and used in order to administer the policy or process any claims in compliance with the local regulations.
  2. Permission to obtain my data from third parties: my health and other data may be obtained from physicians, nursing and hospital staff, other medical institutions, care homes, statutory health insurance funds, my Plan Sponsor, professional associations and public authorities to provide me with insurance cover or process any claims. I agree to release all individuals at these institutions and the health insurer from their respective confidentiality obligations relating to my health data or other data that they are required to share and use for these aforementioned stated purposes.
  3. Sharing my data: my health data may be shared with the institutions set out below for them to use to the same extent, and for the same purposes as the health insurer. I understand that the health insurer has put in place contractual arrangements with these institutions to protect my data. I agree to release all individuals at these institutions and the health insurer from their respective confidentiality obligations relating to my health data or other data that they are required to share and use for the purposes set out below:
    • With independent medical experts if this is necessary to process my claim as per my insurance policy
    • With service providers that perform certain services on behalf of the health insurer, such as claims handling that involve the collection and use of my health and other data, without which the health insurer would not be able to administer my policy or pay any claims due to me.
    • With other health insurers/re-insurers that may be covering the same insurance risk at the same time – multiple insurance – to distribute the payment of any compensation that may be owed to me, or to collaborate in the detection or prevention of fraud and financial crime
If I change my mind about my preferences above, including withdrawing my consent to any of these items, I can inform the companyby emailing: Dataprivacy@nextcarehealth.com