AUTHORISATION FOR RELEASE OF MEDICAL INFORMATION

I, EUGINE SUMANTHA, hereby authorise any organisation or person who has or may have information concerning my
health to furnish International SOS Assistance (Pty) Ltd, who is acting on behalf of Shelf Drilling, and its related
entities, including International SOS group companies and/or their respective representatives and/or agents
(International SOS) with:a. All information pertaining to my medical history (including any condition for which medical advice or treatment was
sought, any form of consultation, investigation, prescription or treatment) and employment history;
b. A medical certificate in the form attached completed by any health provider which International SOS may require.
To the extent applicable, I hereby authorise the disclosure of the travel information attached to this authorization
below.
Purpose: This authorisation is for release of, collection, use, storage, processing, amendment and transferring medical,
travel and other personal data for the purpose(s) of : providing assistance, including arranging to treat your

condition; investigating, assessing and paying and/or obtaining payment for that treatment and assistance;
running International SOS normal business and operations; training and quality assurance purposes; if applicable,
for purposes relating to insurance; to comply with legal obligations and respond to emergencies such as those relating to
public health (the Data Collection Purposes)
I consent to International SOS:
(a) Collecting by using telephone recordings, electronic, paper or other means, processing and using my personal data
for the Data Collection Purposes. I understand that if International SOS does not collect this information, International
SOS may not be able to assist me;
(b) Disclosing my personal data to related entities of Shelf Drilling and other International SOS entities or their respective
representatives and/or agents, my personal representatives or family member involved in my care; (the insurer*, other
insurers* and reinsurers*, insurance reference bureaus*, insurance brokers*, insurance agents* or other intermediaries*,
my employer* or the covered members employer*); law enforcement agencies, investigators, lawyers, assessors,
repairers, advisors and the agent of any of these; wherever they may be located for the Data Collection Purposes; and(*
delete as applicable)
(c) Transferring my personal and medical data outside South Africa, to and from my doctors in my country of origin, and
to and from the doctors where I am currently being treated and to other territories that may not have the same level of
personal data protection.
I understand and agree that:
(a) A copy of International SOS' Customer Personal Data Privacy Statement, including information about my rights and
filing complaints and about accessing, correcting, restricting access to or deleting my personal data may be obtained by
writing to: Privacy Officer , International SOS Assistance (Pty) Ltd or may be accessed through the International SOS
website at: www.internationalsos.com.
(b)This authorisation is valid as soon as it is signed but that I have the right to revoke it at any time by writing to
International SOS at the address, fax or e-mail address set out below, except to the extent that International SOS has
already taken action based on it.
(c) This form and my personal data will be kept no longer than is desirable for the purposes they were collected and,
subject to applicable local law, will be destroyed in accordance with the periods set out in the International SOSs policy
on data retention.
(d) A copy, including photostat, electronic or fax copy of this signed form, shall be considered as effective and valid as the
original and specifically authorise its use as such.
(e) Shelf Drilling and International SOS relies upon the truthfulness of the particulars supplied by me in respect of the
request for assistance.

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NAME OF PATIENT / CASE NUMBER

SIGNATURE
OF
PATIENT
GUARDIAN / RELATIVE:

/ NAME OF SIGNATORY
(please print)

EUGINE SUMANTHA
BJNB014781
Date: APRIL 28, 2016
TREATING PHYSICIAN IN COUNTRY OF ORIGIN:
(please fill in name, address, e-mail address and
telephone number)

Relationship to Patient:

TREATING PHYSICIAN IN CURRENT LOCATION:

(please fill in name, address, e-mail address and
telephone number)

TRAVEL INFORMATION AUTHORISATION (if applicable)

I, EUGINE SUMANTHA hereby authorise any organisation or person who has or may have information concerning my
travel to furnish International SOS, with all itineraries, ticket copies, ticket information and proof of payment
documentation.

Please return as soon as possible to:

International SOS Assistance (Pty) Ltd
Attention: Director of Assistance
Stand 72 (adjoining Grand Central Airport)
New Road, Midrand 1685
Johannesburg - South Africa
Via Fax: Alarm Center Fax: +27 11 541 1076 or email at: 1jhbops@internationalsos.com

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