Accenture Consent Form

CONSENT
I, ________________________, of legal age, hereby declare without compulsion and out of my own
free will, the following:
a) I have been informed that as part of my employment in Accenture, Inc. (Accenture), I will be
enrolled in Accenture’s Health Maintenance Organization (HMO) program with its provider,
Maxicare Healthcare Corporation. This will allow me to avail of health-related services (Benefits
and Services) that are covered under the Agreement between Accenture and Maxicare Healthcare
Corporation.
b) I understand that I may be asked to provide Personal Information 1, including my Sensitive Personal
Information2 (Collectively “PII”) to complete my HMO enrollment. In addition, I have been made
aware that this PII, may be collected, used, processed or shared with the Maxicare Healthcare
Corporation for the following purposes:
i. Provision of the Benefits and Services under the Agreement between Accenture and
Maxicare Healthcare Corporation;
ii. Anonymized profiling or historical statistical analysis for Accenture’s benefit, and for
providing advice or information covering Maxicare Healthcare Corporation‘s products or
services to effectively administer or manage the Accenture account, enhance customer
services to, or to communicate with Accenture for purposes of performing its obligations
under the Agreement in accordance with acceptable and lawful data processing principles. I
have been made aware that this PII may be used by Accenture for such other legitimate
purposes in furtherance of Accenture’s interests, including but not limited to, performance
evaluation, data analytics, management & market research, and automated processing
systems. Accenture may also hold, retain and use this PII for a period reasonably necessary
to complete the purposes I have agreed to herein.
c) I understand that the processing activities enumerated above will be carried out in accordance
with applicable data privacy laws and Accenture’s Policy 90, which together regulate the way in
which Accenture collects and uses personal data and my rights to access and correct my data. A
copy of Policy 90 is available on request and should I have concerns, I can reach out to the
following Accenture Points of Contact:
1
Personal information refers to any information, whether recorded in a material form or not, from which the identity of an
individual is apparent or can be reasonably and directly ascertained by the entity holding the information, or when put together
with other information would directly and certainly identify an individual
2
Sensitive Personal Information refers to personal information:
1. About an individual’s race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations;
2. About an individual’s health, education, genetic or sexual life of a person, or to any proceeding for any offense committed or
alleged to have been committed by such individual, the disposal of such proceedings, or the sentence of any court in such
proceedings;
3. Issued by government agencies peculiar to an individual which includes, but is not limited to, social security numbers,
previous or current health records, licenses or its denials, suspension or revocation, and tax returns; and
4. Specifically established by an executive order or an act of Congress to be kept classified.
Accenture Confidential
Miscen L. Desiderio-Dime, Director of Legal Services, Regulatory & Compliance Operations
Higino Jason A. Justo, GDN Counsel
Cynthia G. Sagmit, Manager for Employee Relations
d) I hereby give my consent to the processing and sharing of my PII and the storage of which for a
time reasonably necessary to carry out the activities as described in the foregoing paragraphs.
e) Further, should I elect to enroll dependent/s, I warrant that I have secured his/her/their consent
for the purposes enumerated above, prior to providing his/her/their PII to Accenture.
I declare the afore-mentioned statements as my own and hereby confirm the same, this
________________.
_______________________
Signature over printed name
Accenture Confidential

Accenture Consent Form

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CONSENT

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