BEAMS Clinic Consent Form for Collection and Use of Personal Information
Purpose
BEAMS Clinic is committed to protecting your personal information in compliance with the Personal Information Protection Act (PIPA) of Bermuda. This form explains why we collect your personal information, how we use it, and how we keep it secure. Please review and sign to provide your consent.
1. Information We Collect
We may collect the following types of personal information:
• Full Name
• Date of Birth
• Address and Contact Information
• Medical History and Records
• Insurance Information
• Emergency Contact Details
• Payment Information
2. Purpose of Collection
We collect this information to:
• Provide medical care and treatment.
• Maintain accurate medical records.
• Coordinate care with other healthcare providers as needed.
• Process billing and insurance claims.
• Communicate with you about appointments, results, and follow-ups.
• Fulfill legal and regulatory requirements.
3. Disclosure of Information
Your personal information may be shared with:
• Healthcare professionals involved in your care.
• Laboratories, diagnostic centers, or other service providers assisting in your treatment.
• Insurance companies for billing purposes.
• Regulatory authorities, as required by law.
We will not disclose your information to third parties for marketing or other purposes without your explicit consent.
4. Security Measures
We use appropriate security measures, including encrypted storage systems and secure communication protocols, to protect your personal information from unauthorized access or breaches.
5. Your Rights
Under PIPA, you have the right to:
• Access your personal information.
• Request corrections to inaccurate or incomplete information.
• Withdraw your consent at any time (subject to legal and medical obligations).
To exercise these rights, contact us at:
Email: privacy@beamsbermuda.org
Phone: +1 (441) 601-8008
6. Retention of Information
We will retain your information only as long as necessary to fulfill the purposes outlined above, or as required by law.
Acknowledgment and Consent
By signing below, I confirm that I have read and understood this consent form. I voluntarily consent to the collection, use, and disclosure of my personal information by BEAMS Clinic as described above.