Medical Form 医疗信息表

This form is used to confirm your consent to our treatment methods and charges, and to authorize the disclosure of relevant information within our team for case discussions and reviews. It is our Code of Conduct and ethical duty to uphold your right to confidentiality; no information will be disclosed unless required by relevant authorities for purposes such as:

• Reimbursement of treatment expenses
• Return-to-work verification (by employer)
• Referral to other physicians, specialists, or hospitals in case of emergency

If disclosure becomes necessary under the above circumstances, we will inform you in writing. You may also withdraw your consent at any time by notifying us in writing.

该表格用于确认您同意我们的治疗方案及收费标准，并授权我们在团队内部披露相关信息，用于病例讨论和医疗评审。保护您的隐私及信息保密是我们的行为准则和道德责任。除相关部门要求（如以下情况）外，我们不会泄露您的个人信息：治疗费用报销、返岗评估（由雇主核实）、在紧急情况下转介其他医生 / 专家或医院。若确需在上述情况下披露信息，我们将以书面形式告知您。您也可以随时通过书面通知撤回此类授权。