RELEASE OF MEDICAL INFORMATION FORM

Patient Name : …………………………………………………… Date of birth : ……………………………………………………

Nationality : …………………………………………………… ID Number : …………………………………………………….
[The followings to be read and signed by the above-named patient]

A. AUTHORISATION

(i) I hereby authorise the following individual, institution or organisation:-

to provide access and furnish all necessary and relevant reports and/or information pertaining to my medical records (these m ay include
information regarding past medical history, psychological notes, drug or alcohol abuse notes, AIDS and other sexually transmitted disease
related information) to MEDIKA PLAZA, addressed at Beltway Office Park, Annex Building, Ground Floor Jl.TB Simatupang No.41, Jakarta
Selatan 12550, including its associate companies and affiliates, as may be required; and

(ii) I further authorise MEDIKA PLAZA, including its associate companies and affiliates to have access, to use and to receive such reports and/
or information pertaining to my medical records (including information regarding past medical history, psychological notes, drug
or alcohol abuse notes, AIDS and other sexually transmitted disease related information) from the above- named party for the purpose
of conducting evaluation and utilisation review of the health care services rendered as well as to coordinate, assess and determine the
benefits and/or reimbursements in connection with my health or medical insurance coverage.

This information may be disclosed and furnished to the relevant insurance companies, physicians or medical practitioners, other health care
providers who may be involved in my treatment directly or indirectly, and other third parties acting on behalf of my insurer.

B. SIGNATURE

I have had full opportunity to read and consider the contents of this authorisation, and I understand that, by signing this for, I am confirming
my authorisation of the use and/ or disclosure of my protected health information, as described on this document.

If I sign this form as the Patient's Legal Representative, I understand that all references in this form to "I", "me" or "my" refer to the Patient.

Print Name:…………………………………………………………………….

Signature: Date:………………………………………………………………

** If this authorisation is being signed by a personal representative on behalf of the patient, please complete the following:

Print Name of Patient's Legal Representative: Relationship to Patient:

Signature: Date:…………………………………………………………………..