Medical Records Office

5 Lower Kent Ridge Road

Kent Ridge Wing 2, Level 1
Singapore 119074
Tel: (65) 6772 5163
Email: MedicalReportSection@nuhs.edu.sg

Application & Consent for Release of Medical Information (Form A)

Brief Notes (Refer to the attached NOTES for full details):
 As a general rule, application can only be made by the Patient. (Please refer to Note nos. 1-6 for exceptions and details). This is in accordance with the
Personal Data Protection Act (No.26 of 2012) in the absence of a Legally Appointed Representative.
 Scanned copies / photocopies of Patient’s and Applicant’s NRIC and all relevant documents (e.g. birth certificate, marriage certificate, grant of probate,
lasting power of attorney) as proof of the Applicant’s relationship to Patient are required. (Please refer to Note no.8 for details)
 The release of Medical Information is subject to official approval by National University Hospital (Singapore) Pte. Ltd. “(NUH(S) Pte. Ltd.”)

Patient’s Particulars
Patient’s Name: ID/ HRN No.:
Contact No.: Mobile No.:
Mailing Address: Postal Code: ( )
Admission Period : Attending Doctor:

Fees S$ Service
Select Report Type
(GST Incl.) Code
☐ Ordinary Medical Report 80.25 950003
☐ Specialist Medical Report (excludes clinic consultation charges) 180.20 950006
☐ Specialist Medical Report (Psychiatric) 180.20 950006
☐ Second Opinion (non-NUH Patient) 267.50 950010
☐ Simple Insurance form (Outpatient only) 21.40 950002
☐ Completion of Insurance Form (Ordinary) 80.25 950001
☐ Completion of Insurance Form (Specialist/Disability Claim) 180.20 950006
☐ Completion of Insurance Form (Psychiatric) 180.20 950006
☐ Workmen Compensation Form 80.25 950004
☐ Workmen Compensation Objection Form 357.00 950011
☐ Lasting Power of Attorney Report 180.20 950006
☐ Mental Capacity Medical Report 438.70 950015
☐ Therapy Report 80.25 950003
☐ Duplication of Investigation Results / Inpatient Day Surgery or Discharge Summary (per copy) 5.35 950008
☐ Certified True Copy of Medical Report/ Medical Certificate (Per copy) 10.70 950007
☐ Duplication of Referral Letter (from GP/Polyclinic) / Others: 0.00 -
In addition to the medical report fees, I undertake to pay any additional charges, such as X-ray or laboratory charges, that maybe
incurred in the preparation of the report.
Purpose of Report:
☐ Continuity of Care ☐ Insurance claims ☐ Personal ☐ Employment ☐ Second Opinion ☐ Legal Proceedings
☐ For informing Employer/ Next-of-kin* who will be responsible for the settlement of medical expenses incurred (*Delete accordingly)
Name of Company or Person: ________________________________________________________ Contact no.: ___________________
Address of Company or Person: ____________________________________________________________________________________
Preferred Mode of Delivery
☐ Self-collect: I will personally collect the report once it is ready. I am aware that I will need to furnish my NRIC upon collection and
that the medical report cannot be released if I am unable to do so.
☐ Collected by Representative: The report(s) will be collected by my representative. I am aware that I have to produce the required
documents required in Form B on the day of collection and that the medical report cannot be released if I am unable to do so.
(Please complete Form B)
☐ Mail: Send to the address of Patient/ Applicant* (Delete accordingly) as indicated by Normal / Local registered mail* (Delete accordingly)
☐ Email to this email account: ________________________________________________________________________

Consent: I consent National University Hospital(S) Pte. Ltd. (“NUH”) to the release of my medical information and/or medical records
(including but not limited to my care and/or treatment plan) information. By signing on the consent below, I confirm that I have read and
understood the Notes on Application for the Release of Medical Information. I agree that the Institution(s) of NUH shall not be liable for any
omissions, false or incorrect information given by me under this application and I will indemnify the Institution(s) for any claims arising from this
application. I acknowledge and agree that if I provide an overseas postal address or if I open the email overseas, the overseas country may not have
any data protection laws or may have data protection laws dissimilar to Singapore’s Personal Data Protection Act 2012, and I do so at my own risk.

Signature of Patient Signature of Applicant (if applicable) Relationship to Patient (if applicable)
Date: Date: (Refer to Note nos. 1-7)
Date received: Payment posted by/ Date: MR No.:
For official use only:

MRO-FORM-GEN-003 Page 1 of 3 R9-08-18

Types of Medical Information / Services

Completion of Detailed Insurance Form (Ordinary) Incapacity Under Compensation (Medical Board) Regulations 2005 -
It is a detailed insurance claim form to be completed by the doctor. Medical Report on Traumatic Injuries for Workmen's Compensation"
The form will require information such as: diagnosis, details of injuries form prescribed by the Ministry of Manpower.
suffered, treatment given.
Mental Capacity Act Report
Completion of Insurance Form (Specialist or Disability Claim) This report is prepared by the patient's psychiatrist in response to
It is a detailed insurance claim form provided by the insurance requests that require a professional opinion with regards to the
company for the doctor to assess the patient's disability status. The patient's prognosis and disabilities. It is based on an actual
form will require information such as: prognosis, diagnosis, details of assessment of the patient and may involve a review at the
injuries suffered, treatment given. Consultation fees will be charged Psychological Medicine Specialist Outpatient Clinic. Applicant has to
separately by the clinic on the day of the assessment. make an appointment with the clinic for the affidavit to be signed
together with the Commissioner of Oath.
Simple insurance form (Outpatient Only)
It is a simple insurance form usually requested by insurance company LPA (Lasting Power of Attorney) Report
of a Group Department. The form will require information such as: Issuance of LPA Certificate. Medical report fees do not include the
Diagnosis, Diagnosis code, Procedure, Procedure code, Referring consultation fees, if patient has to be assessed by a specialist first for
doctor. the purpose of providing these reports. Consultation fees will be
charged separately by the clinic on the day of the assessment.
Ordinary Medical Report
It is a report put up by the doctor based on patient's medical records. Second Opinion Report (non-NUH patient only)
It is a factual record of the patient's medical problem. A medical report requested by non-NUH patient seeking second
opinion from NUH specialist. An appointment will be arranged for
Specialist Medical Report Consultant to assess the patient. Patients may be required to provide
This is a detailed medical report that usually highlights the history of the attending specialist with their previous medical report or
medical complaint or injury. The doctor will include findings of the investigation results.
assessment as well as their opinion and prognosis of the patient. For
Orthopaedics’ cases, an appointment will be arranged for the patient Investigation Results / Inpatient Discharge Summary/ Memo/
to be reviewed by the doctor. For other disciplines, an appointment Day Surgery Report
would only be arranged if the doctor request on a needs basis. Photocopy of investigation results such as X-ray reports, CT scan
Consultation fees will be charged separately by the clinic on the day reports, blood test results, ECG reports, Histopathology reports,
of the assessment. Cytogenetic reports, Bone Density Report and Urine Test Result.
Inpatient Discharge Summary is a document that provides a
Specialist Psychiatrist Report summary of the patient’s medical condition, investigations done and
This report is prepared by the patient's psychiatrist in response to medication given during a specific hospitalization episode. Memo is
requests that require a professional opinion with regards to the a one or two statement from doctor to state patient’s diagnosis with
patient's prognosis and disabilities. It is based on an actual no explanation of medical condition. Day Surgery Report is a
assessment of the patient and may involve a review at the duplicate copy of the Day Surgery Discharge Summary. It will provide
Psychological Medicine Specialist Outpatient Clinic. Consultation brief information of the surgery, diagnosis and procedure.
fees will be charged separately by the clinic on the day of the
assessment. Duplication of Medical Certificate/ Medical Report
It is an application for a certified true copy of medical certificate for
Workmen Compensation Assessment hospitalization/outpatient medical leave issued by doctors or a
This is an assessment to determine work-related injuries, the degree duplicate copy of medical report that was previously applied before.
and period of disability for workmen’s compensation purpose under
the Workmen’s Compensation Act. Scope of the report is as per Therapy Report
"Medical Report on Traumatic Injuries for Workmen's Compensation" It is a report put up by either Physiotherapist, Occupational Therapist,
form prescribed by the Ministry of Manpower. Speech therapist or Podiatrist on patient’s medical records. It is a
factual record of the patient’s medical problem such as diagnosis,
Workmen Compensation Objection Report treatment given and performance of the patient based on last therapy
This is a referral from Ministry of Manpower to assess and re- visit.
determine work-related injuries, the degree and period of disability
when any of the parties (insurer, employer or injured worker) object Referral Letter
to the results of the initial workmen’s compensation assessment. A duplicate copy of patient’s referral letter from Polyclinic and/or
Scope of the report is as per "Referral of Objection to Permanent General Practitioners.

MRO-FORM-GEN-003 Page 2 of 3 R9-08-18

 - These notes are to be retained by the Applicant –
NOTES ON APPLICATION & CONSENT FOR RELEASE OF MEDICAL INFORMATION
1) In accordance to the Personal Data Protection Act (No.26 of Representative. Please note the Will itself shall not suffice as
2012), the application can only be made by the patient, verification documentation.
a) except if the patient is f) For deceased patient, where the applicant is the nearest
i) a minor. relative the following documents are required:
ii) deceased. i) Scanned copy / photocopy of the death certificate; and
iii) mentally incapacitated. ii) Copy of the completed “Additional Consent & Declaration
for Release of Medical Information for Deceased Patient”
b) or if the report is for workmen compensation. (i.e. “Form C”). Section 1 must be completed by the
i) Workmen Compensation reports can be applied by the applicant. Section 2 must be completed by all living
patient or his / her employer. The completed report will be spouse(s) / children / parent / siblings of the deceased
given directly to the Ministry of Manpower. patient (other than the applicant), if the applicant is not the
2) If the patient is a minor, the application is to be made by either of only living spouse / child / parent / sibling. Scanned copies
the patient’s parents or legal guardian. A minor is someone who / photocopies of the relevant verification documents (e.g.,
is below 21 years old, who is not an active National Serviceman, marriage certificates, birth certificates) are to be provided
and who is not married or a widower or widow. by each declarant (i.e. spouse / child / parent / sibling) as
proof of relationship to the deceased patient.
3) If the patient is deceased,
g) For patient who lacks mental capacity, and for whom the
a) the application is to be made by the Legally Appointed applicant is the Main Caregiver:
Representative of the Estate. This is either an executor of the
deceased’s “Will” who has been granted probate, or a person i) Copy of the completed “Additional Declaration for Release
who has been appointed as an administrator of the of Medical Information for Patient with Mental Incapacity”
deceased’s estate by the Singapore Court. (i.e. Form D). This is to be completed by the Main
Caregiver.
b) In circumstances where the deceased has no ‘Will’ and no
person has been appointed as the Legally Appointed ii) If there is more than one Main Caregiver, the declaration
Representative of the Estate, then the application can be has to be made by each and every Main Caregiver, by
made by the deceased’ nearest relative (who is living and has signing this Additional Declaration for Release of Medical
the mental capacity to do) as prioritised below. The nearest Information for Patient with Mental Incapacity” (i.e. Form
relative is the individual listed below, and is the elder or eldest D) separately.
of two or more such individuals: h) If patient is a foreign worker who has left Singapore or has
i) First priority: Spouse. gone missing, and for whom the applicant is the Employer:
ii) Second priority: Child. i) Copy of the completed “Indemnity Form for Workmen
Compensation” (i.e. Form E) by the Employer. (Strictly for
iii) Third priority: Parent. application of Discharge Summary only).
iv) Fourth priority: Sibling. ii) Scanned copies/ photocopies of MOM’s letter to verify
v) Fifth priority: Other relation. that patient has left Singapore and/or police report for
4) If the patient lacks mental capacity, and in accordance to the missing worker(s).
Mental Capacity Act (Cap 177A), 8) NUH (S) Pte. Ltd. can only process your application upon
a) the application is to be made by the Legally Appointed fulfilling the verifications and receipt of all necessary forms,
Representative, who is a Donee of a Lasting Power of supporting documents and payment.
Attorney granted by the patient, or by a Deputy appointed for 9) Application method:
the patient by the court. a) Online: www.healthhub.sg via SingPass
b) If the patient does not have a Legally Appointed b) Email: MedicalReportSection@nuhs.edu.sg or phone call at
Representative, then the application is to be made by the
patient’s Main Caregiver. Tel: (65) 6772 5163
5) Psychiatric medical reports cannot be addressed or released to c) In person:
the patient’s family members unless authorisation is given (i.e. Medical Records Office
Form B) 5 Lower Kent Ridge Road, Kent Ridge Wing 2, Level 1
6) Application that has a blank insurance form to be completed by Singapore 119074
doctor can be submitted by the patient or a representative on Operating Hours:
behalf, provided that the blank insurance form is signed by the Monday - Friday: 8.30am - 5.30pm
patient. Saturday, Sunday & Public Holiday: Closed
7) Forms and supporting documents required are: 10) Mode of Payment:
a) Copy of the completed “Application & Consent for Release of a) NETS (Preferred), Credit Card (if application is made in
Medical Information” (i.e. “Form A”). person, no cash payment allowed)
b) Scanned copies / photocopies of the Patient’s NRIC (or b) Cheque (if application is sent via mail) should be crossed and
appropriate identification documents), both front and back made payable to National University Hospital (Singapore)
views. Pte. Ltd.
c) Scanned copies / photocopies of the Applicant’s NRIC (or 11) As a general guide, the time required for processing medical
appropriate identification documents), both front and back reports is about eight weeks, from the date of receiving the
views and a copy of completed “Authorisation for Application completed forms, or the date of medical appointment for
of Medical Report (i.e. “Form B1”). assessment, whichever comes later. Duplicate copies of
d) Scanned copies / photocopies of all relevant documents (e.g. investigation results or medical certificate can be collected on the
Birth Certificate, Marriage Certificate, Grant of Probate, Letter spot if the request is made in person at the respective application
of Administration, Lasting Power of Attorney, Order of the locations.
Court (Appointment of Deputy) as proof of the applicant’s 12) Administrative charges of one-third of the payment made will be
relationship to patient, if the applicant is not the patient. imposed if a cancellation request is made while them medical
e) For deceased patient, scanned copy / photocopy of the death report is being processed.
certificate and relevant verification documents, e.g. Grant of 13) The release of the medical information is subjected to the official
Probate, Letter of Administration, or any other legal document approval by NUH(S) Pte. Ltd.
that certifies the applicant is the Legally Appointed 14) A refund of the payment will be made in the event that the medical
information cannot be release.
MRO-FORM-GEN-003 Page 3 of 3 R9-08-18