電子健康紀錄互通系統 (互通系統)
Electronic Health Record Sharing System (eHRSS)
登記及互通同意書 (供非親身前往辦理有關申請者填寫)
Registration and Sharing Consent Form
(To be Completed by Applicants Registering by Not-in-person Means)
登記資料 Registration Information
1 - 醫護接受者 (病人) 資料
PART 1 - Healthcare Recipient's (Patient's) Particulars
英文姓氏
Surname in English
英文名
Given Name in English
中文姓名 (先寫姓氏) (如適用)
Name in Chinese (if applicable)
香港身份證號碼
HK Identity Card No.
( )
出生日期
Date of Birth
Day
Month
Year
性別 Sex Male Female
如非香港身份證持有人,請填寫其他身份證明文件資料
For non HK Identity Card holder, please fill in information of other identity document
類別 Type 簽發國家/地區 Issuing Country/Region 證件號碼 Document No.
2 - 通訊資料及方式
PART 2 - Communication Information and Means
聯絡電話號碼 (至少提供一個號碼,如非本港電話號碼,請提供國家/地區代碼)
Contact Telephone No. (At least provide one contact no. For non-local telephone no., please provide country/area code(s))
手提電話
1
Mobile
其他電話 Other Phone 電郵地址 Email Address
通訊地址 Correspondence Address
通訊語言 Language for Communication 中文 Chinese 英文 English
選擇以下其中一種通訊方式以收取有關閣下的電子健康紀錄的通知
Select one of the following communication means for receiving notification related to the electronic health record (eHR) of the
healthcare recipient in eHRSS
手機短訊 SMS
1
電子郵件 Email
郵寄 Postal Mail
本人拒絕接收有關電子健康紀錄被取覽的通知 I refuse to receive notification whenever the eHR has been accessed
1
如選擇以手機短訊收取有關的通知,請提供本港手提電話號碼
If SMS is selected, please provide a local mobile no. for receiving related notification
RE(C)01 (12/2017)
Page 1
3 - 給予醫護提供者 (醫護機構) 互通同意 (如適用)
PART 3 - Sharing Consent to Healthcare Provider (If applicable)
此部分適用於親身前往電子健康紀錄登記站遞交之申請。
This section is applicable to registration in person at eHR Registration Centres.
填寫前請先查閱互通系統網站有關醫護提供者(醫護機構)的資料
(網址 : http://www.ehealth.gov.hk/tc/ehrss/healthcare_provider_list/search.html)
Please refer to the eHRSS website for information of healthcare providers before filling in this part
(website : http://www.ehealth.gov.hk/en/ehrss/healthcare_provider_list/search.html)
本人同意給予以下的醫護提供者互通同意:
I agree to give Sharing Consent to the following healthcare provider:
醫護機構編號
HCP Number
醫護機構名稱
HCP Name
給予該醫護機構無限期互通同意
2
Give Indefinite Sharing Consent
2
to concerned healthcare provider
只給予該醫護機構為期一年的互通同意
3
Give only One-year Sharing Consent
3
to concerned healthcare provider
完成登記後,醫護接受者亦可在接受醫護服務時向個別醫護機構給予互通同意。
After registration, healthcare recipient may give sharing consent to individual healthcare provider when receiving healthcare.
2
無限期的互通同意︰同意會維持有效直至醫護接受者或其代決人撤銷或更改有關同意、退出或取消登記為止
Indefinite Sharing Consent: Consent will remain valid until revoked or updated by the healthcare recipient or the substitute decision maker, or the
healthcare recipient's registration is withdrawn or cancelled
3
為期一年的互通同意︰同意將會在一年後無效或直至醫護接受者或其代決人撤銷或更改有關同意、退出或取消登記為止
One-year Sharing Consent: Consent will expire after 1 year or lapse if revoked or updated by the healthcare recipient or the substitute decision
maker, or the healthcare recipient's registration is withdrawn or cancelled
4 - 醫護接受者簽署及聲明
PART 4 - Healthcare Recipient's Signature and Declaration
如醫護接受者為年滿十六歲並有能力給予同意的人士,但未能親身前往辦理有關申請,可授權他人遞交有關申請,並須同時填寫第
4及第5部。
If the healthcare recipient is aged 16 or above and is capable of giving consent but cannot submit application in person,
the healthcare recipient may authorise a representative to submit application on his / her behalf. Please fill in PART 4 and
PART 5.
如醫護接受者為十六歲以下兒童或年滿十六歲但無能力給予同意的人士,此欄無須填寫,而須由其代決人
4
提出申請並填寫第6及第
7部。
If the healthcare recipient is a minor aged under 16 or a person aged 16 or above but incapable of giving consent, no entry
to this part is required, and the application should be submitted by a Substitute Decision Maker
4
on his / her behalf. Please
fill in PART 6 and PART 7.
在簽署本表格後 本人確認-
(a) 所填報以支持本申請的資料均屬真確無訛。
(b) 本人已就登記參加互通系統給予「參與同意」,以及明白藉此本人被視為已向衞生署及醫院管理局給予「互通同意」。
(c) 本人已根據本表格內有關章節中所列明的期限給予醫護提供者「互通同意」。
(d)本人已參閱及明白「參與者須知」,當中包括以下部分(i)已給予的「參與同意」的意義,以及(ii)就給予個別醫護提供者「互通同
意」的意義,以讓其根據《電子健康紀錄互通系統條例》(625) 取得及互通本人存放於互通系統的資料。
(e) 本人已參閱及明白「收集個人資料聲明」。
By signing this form, I confirm that -
(a) all information given to support this application is true and correct.
(b) I have given my joining consent to participate in eHRSS and I understand that by doing so, I am taken to have given my sharing
consent to the Department of Health (DH) and the Hospital Authority (HA).
(c) I have given my sharing consent to the healthcare provider according to the terms stated in the above relevant section of the
form.
(d) I have read and understood the "Participant Information Notice" including section(s) regarding (i) the meaning of the joining
consent that I have given; and (ii) the meaning of sharing consent given to individual healthcare provider(s) to obtain and share my
data contained in eHRSS in accordance with the Electronic Health Record Sharing System Ordinance (Cap. 625).
(e) I have read and understood the "Personal Information Collection Statement".
醫護接受者簽署 Healthcare Recipient's Signature
日期 Date
RE(C)01 (12/2017)
Page 2
5 - 授權書 (如適用)
PART 5 - Authorisation Letter (If applicable)
本人
I
英文姓氏
Surname in English
英文名
Given Name in English
中文姓名 (先寫姓氏) (如適用)
Name in Chinese (if applicable)
未能親身前往電子健康紀錄登記站或電子健康紀錄申請及諮詢中心遞交有關登記參加互通系統及給予有關醫護提供者互通同意之
申請。
am unable to come in person to eHR Registration Centres or eHR Registration Office to submit my application to register with
eHRSS and to give sharing consent to healthcare provider.
本人現授權
I hereby authorise^
英文姓氏
Surname in English
英文名
Given Name in English
香港身份證號碼
HK Identity Card No.
中文姓名 (先寫姓氏) (如適用)
Name in Chinese (if applicable)
如非香港身份證持有人,請填寫其他身份證明文件資料
For non HK Identity Card holder, please fill in information of other identity document
類別 Type 證件號碼 Document No.
代表本人遞交有關申請,並附上本人身份證明文件副本以供查證。
to submit this application on my behalf. A copy of my identity document is attached for identity authentication.
醫護接受者簽署 Healthcare Recipient's Signature
日期 Date
^
獲授權者須出示身份證明文件及提供個人資料作核對身份及就醫護接受者有關之申請作保存紀錄之用。
Authorised Person should produce identity document and provide his/her personal data for identity authentication and
maintenance of records relating to the application of the healthcare recipient.
RE(C)01 (12/2017)
Page 3
6 - 代決人 (適用於由代決人提出申請
4
)
PART 6 - Substitute Decision Maker (For application submitted by Substitute Decision Maker)
4
代決人資料 Substitute Decision Maker's Particulars
英文姓氏
Surname in English
英文名
Given Name in English
中文姓名 (先寫姓氏) (如適用)
Name in Chinese (if applicable)
香港身份證號碼
HK Identity Card No.
( )
與醫護接受者關係
Relationship with Healthcare Recipient
聯絡電話號碼
Contact Telephone No.
如非香港身份證持有人,請填寫其他身份證明文件資料
For non HK Identity Card holder, please fill in information of other identity document
類別 Type 證件號碼 Document No.
4
有關代決人安排 Arrangement of Substitute Decision Maker
如醫護接受者為十六歲以下兒童或年滿十六歲但無能力自行給予同意的人士,代決人可作其代表處理其有關互通系統的事宜(詳情請參閱參與者須知)
For healthcare recipient who is a minor aged under 16 or a person aged 16 or above but incapable of giving consent, a Substitute Decision Maker
may manage matters related to the healthcare recipient's eHRSS participation on his/her behalf (Please refer to Participant Information Notice for
details)
7 - 代決人簽署及聲明 (適用於由代決人提出申請)
PART 7 - Substitute Decision Maker's Signature and Declaration (For application submitted by Substitute Decision Maker)
在簽署本表格後,本人確認-
(a) 所填報以支持本申請的資料均屬真確無訛。
(b) 本申請是由本人代表醫護接受者提出,並且是以該醫護接受者的名義提出的。
(c) 本人已代表醫護接受者就提出登記參加互通系統給予「參與同意」,以及明白藉此該醫護接受者被視為已向衞生署及醫院管理
局給予「互通同意」。
(d) 本人在代表醫護接受者提出本申請時,本人是陪伴該醫護接受者,並已顧及該接受者在有關情況下的最佳利益。
(e) 就本人所知所信,本人在提出本申請時醫護接受者是未滿十六歲;或年滿十六歲但精神上無行為能力、無能力處理其本身事
務、或無能力處理有關參與或退出互通系統的事宜。
(f) 本人已參閱及明白「參與者須知」,特別是「代決人為醫護接受者處理登記事宜時應注意事項」,及以下部分(i)代表醫護接受
者已給予「參與同意」的意義,以及(ii)就代表醫護接受者給予個別醫護提供者「互通同意」的意義,以讓其根據《電子健康紀錄
互通系統條例》(第625章) 取得及互通醫護接受者存放於互通系統的資料。
(g) 本人已參閱及明白「收集個人資料聲明」。
By signing this form, I confirm that -
(a) all information given to support this application is true and correct.
(b) this application is made on behalf of and in the name of the healthcare recipient.
(c) I have given my joining consent on behalf of the healthcare recipient to participate in eHRSS and I understand that by doing
so, the healthcare recipient is taken to have given his/her sharing consent to the Department of Health (DH) and the Hospital
Authority (HA).
(d) when making the application on behalf of the healthcare recipient, I am accompanying the healthcare recipient and had
regard to the best interests of him/her.
(e) to the best of my knowledge and belief that at the time this application is made, the concerned healthcare recipient is under
the age of 16; or is aged 16 or above and is mentally incapacitated, incapable of managing his/her own affairs, or incapable of
managing matters relating to the participation in / withdrawal from eHRSS.
(f) I confirm that I have read and understood the "Participant Information Notice", in particular “Important Notes for SDM
Handling Registration Matters on Behalf of an HCR”, and section(s) regarding (i) the meaning of the joining consent that I have
given on behalf of the healthcare recipient; and (ii) the meaning of sharing consent given on behalf of the healthcare recipient
to individual healthcare providers to obtain and share the healthcare recipient's data contained in eHRSS in accordance with
the Electronic Health Record Sharing System Ordinance (Cap. 625).
(g) I have read and understood the "Personal Information Collection Statement".
代決人簽署 Substitute Decision Maker's Signature
日期 Date
RE(C)01 (12/2017)
Page 4
遞交登記及互通同意書注意事項
Points to Note - Submission of Registration and Sharing Consent Form
如親身前往辦理有關申請,則無須填寫此同意書。
If you submit the application in person, you do not need to complete this form.
遞交方法 Submission Methods:
郵寄 /
傳真 /
投遞箱
By Post /
Fax /
Drop-in
Box
已年滿十六歲或以上的人士,須遞交:
For person aged 16 or above, please submit:
(1) 此表格 this form
以代決人身份提出申請的人士,須遞交:
For Substitute Decision Maker (SDM) submitting the application on behalf of Healthcare Recipient
(HCR), please submit:
(1) 此表格 this form
(2) 雙方關係證明副本 copy of relationship proof*
(遞交地址顯示於本文件下方 address shown at the bottom of this document)
授權他人
前往遞交
By
Authorised
Person
獲授權者須前往電子健康紀錄登記站
#
遞交
#
The Authorised Person (AP) should submit the following at eHR Registration Centres :
(1) 此表格 this form
(2) 醫護接受者身份證明文件副本 copy of HCR’s identity document
(3) 獲授權者身份證明文件 AP’s identity document
當申請被接納後 When the application is accepted:
(
只適用於透過郵寄、傳真或投遞箱遞交的申請
For applications submitted by post, fax or drop-in box only)
1
透過所選擇的通訊方式收取啟動電子健康紀錄的系統通知
System notification for eHealth record activation will be received via the selected communication means
2
醫護接受者或其代決人(如適用)須攜同遞交申請時所用的身份證明文件,於下一次前往已註冊互通系統的私營醫護機構接受
醫護服務時,或前往電子健康紀錄登記站
#
供職員核對身份以啟動電子健康紀錄。屬於互通系統可互通資料範圍內的電子健
康紀錄將於啟動後約30分鐘至1小時內上載至系統。
The HCR or his/her SDM (if applicable) may bring along the same identity document(s) (as the ones used when making
this application) for identity authentication to proceed with record activation when the HCR next visits a registered private
healthcare provider providing healthcare to the HCR or at eHR Registration Centres
#
. Electronic health record within the
eHRSS sharable scope would be shared to the system within about 30 minutes to 1 hour after record activation.
3
RE(C)01 (12/2017)
成功啟動後,將收到確認登記信及透過所選擇的通訊方式收到授權號碼。授權號碼或身份證明文件可用於管理給予醫護機構
的互通同意 (醫院管理局及衞生署除外)
Upon successful record activation, confirmation letter and system notification with access key will be received via the
selected communication means. The access key or identity document may be used for managing sharing consent given
to healthcare providers (except HA and DH).
*
以下類別的代決人須連同關係證明副本遞交申請 The following types of SDM should submit the application together with a copy of the relationship proof:
(1)根據《未成年人監護條例》(13) 或《精神健康條例》(136) 委任的監護人;(2)社會福利署署長或根據《精神健康條例》(136) 委任為監護人的任
何其他人;(3)獲法院委任以處理該接受者事務的人士;(4)正在或即將向該接受者提供醫護服務的訂明醫護提供者。
(1) Guardian appointed under Guardianship of Minors Ordinance (Cap. 13) or Mental Health Ordinance (Cap. 136); (2)The Director of Social Welfare or any other
person as guardian under Mental Health Ordinance (Cap. 136); (3)Person appointed by court to manage the person's affairs; (4)The prescribed healthcare
provider who provides or is about to provide healthcare to the person.
#
醫院管理局或衞生署轄下的電子健康紀錄登記站、電子健康紀錄申請及諮詢中心、或為醫護接受者提供醫護服務的私營醫護機構的電子健康紀錄登記站。
電子健康紀錄登記站名單載於 (http://www.ehealth.gov.hk/tc/ehrss/healthcare_provider_list/search.html)
Registration centres in Hospital Authority (HA) or Department of Health (DH), eHR Registration Office, or registration centres of private healthcare providers
providing healthcare to HCR. A list of eHR Registration Centres is available at (http://www.ehealth.gov.hk/en/ehrss/healthcare_provider_list/search.html)
電子健康紀錄申請及諮詢中心 eHR Registration Office
地址 Address: 香港九龍灣展貿徑1號九龍灣國際展貿中心111193
Unit 1193, 11/F, Kowloonbay International Trade & Exhibition Centre, 
1 Trademart Drive, Kowloon Bay, H.K.
傳真號碼 Fax no.:
3467 6099
辦公時間 Office Hours:
星期一至五 Monday to Friday
9:30-12:30 & 14:00-17:00
星期六、日及公眾假期休息
Closed on Saturdays, Sundays and public holidays
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PICS (HCR & SDM) V1.4 (24 Nov 2020)
PERSONAL INFORMATION COLLECTION STATEMENT
Purposes of Collection
We, the Electronic Health Record Office under the Food and Health Bureau of HKSARG, may
collect your personal information including name, date of birth, gender, identity document number,
and contact information (e.g. correspondence address, telephone number(s) and email address) if
you are a healthcare recipient.
We may collect the personal information of you and the healthcare recipient concerned, including
name, identity document number, contact information (e.g. correspondence address, telephone
number(s) and email address) and details of your relationship with the healthcare recipient, if you
are a substitute decision maker (if applicable) applying for the healthcare recipient in relation to
matters of his/her registration and use of the Electronic Health Record Sharing System (eHRSS).
We may also receive information about you from other healthcare recipients, when they register
you as their authorised person or contact person in eHRSS and your personal information including
name and contact information (e.g. correspondence address, telephone number(s) and email
address) will be collected.
The personal data and information we collect from you is for your application and registration and
use of eHRSS; or for a healthcare recipient to apply and register to eHRSS with you as his/her
substitute decision maker, authorised person, or a contact person, and related matters under the
Electronic Health Record Sharing System Ordinance (Cap 625) (eHRSSO). Such matters include
but are not limited to the following: the giving of and management of joining consent and/or sharing
consent, updating of information in eHRSS, receipt of eHRSS notifications, withdrawal from
eHRSS.
The health information of the registered healthcare recipient will be shared among healthcare
providers, who have obtained sharing consent from that registered healthcare recipient or his/her
substitute decision maker, via eHRSS. We may collect the personal information of the healthcare
recipient concerned, including name, date of birth, gender and identity document number, and
details of your relationship with the healthcare recipient, if you are caregiver (if applicable) of the
healthcare recipient, in relation to matters of the use of 醫健通 eHealth App. The other caregiver(s)
(if applicable) of the healthcare recipient concerned can also review your name and details of the
access(es) you made to the healthcare recipient's eHR account via 醫健 eHealth App.
Using your personal information in eHRSS for direct marketing is an offence.
PICS (HCR & SDM) V1.4 (24 Nov 2020)
Classes of Transferees
Except with your prior consent, we will not transfer or disclose the collected personal data and
information to any third party except as stated below:
1. the Department of Health, Hospital Authority or any person or entity whom we may appoint in
writing to assist the Commissioner for the Electronic Health Record in performing a function
and exercising a power, pursuant to eHRSSO;
2. any personnel, agent, adviser, auditor, contractor or service provider engaged by us to provide
services or advice (e.g. technical, security or data processing service, etc.) in connection with
our operations;
3. any person to whom we are required to make disclosure to under any law or court order
applicable in Hong Kong.
Access and Correction of Your Personal Data
You have the rights of access and correction of the personal data provided under Personal Data
(Privacy) Ordinance and the application forms for access to or correction of personal data can be
obtained from the eHRSS website (www.ehealth.gov.hk). You may also contact the Electronic
Health Record Registration Office for more information. A non-excessive fee will be charged for
complying with your data access request.
Enquiries
Enquiries concerning personal data provided, including data access requests and data correction
requests should be addressed to:
Electronic Health Record Registration Office
Address: Unit 1193, 11/F, Kowloonbay International Trade & Exhibition Centre, 1 Trademart Drive,
Kowloon Bay, Hong Kong
Hotline: 3467 6300
Fax: 3467 6099
Email: ehr@ehealth.gov.hk