{"id":15621,"date":"2019-10-23T12:42:09","date_gmt":"2019-10-23T10:42:09","guid":{"rendered":"https:\/\/www.grupopoliclinica.es\/impreso-de-solicitud-de-documentacion-clinica\/"},"modified":"2021-05-10T13:03:46","modified_gmt":"2021-05-10T11:03:46","slug":"impreso-de-solicitud-de-documentacion-clinica","status":"publish","type":"page","link":"https:\/\/www.grupopoliclinica.es\/de\/impreso-de-solicitud-de-documentacion-clinica\/","title":{"rendered":"Impreso de solicitud de documentaci\u00f3n cl\u00ednica"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15621\" class=\"elementor elementor-15621 elementor-8374\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-070ddb1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"070ddb1\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-f9e966d\" data-id=\"f9e966d\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ea29ce2 elementor-widget elementor-widget-heading\" data-id=\"ea29ce2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Impreso de solicitud de documentaci\u00f3n cl\u00ednica<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3714d56 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"3714d56\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" id=\"de_solicitud_documentacion_clinica\" name=\"DE Impreso de solicitud de documentaci\u00f3n cl\u00ednica\" aria-label=\"DE Impreso de solicitud de documentaci\u00f3n cl\u00ednica\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"15621\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3714d56\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5130eef elementor-col-100\">\n\t\t\t\t\t<b>DATOS DEL PACIENTE:<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre y apellidos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-datebirth elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-datebirth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFecha de nacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[datebirth]\" id=\"form-field-datebirth\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dni elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dni\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDNI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dni]\" id=\"form-field-dni\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-phone elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-phone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de contacto (m\u00f3vil o fijo)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[phone]\" id=\"form-field-phone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Nur Nummern oder Telefon-Zeichen (#, -, *, etc) werden akzeptiert.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a403b42 elementor-col-100\">\n\t\t\t\t\t<br>\n<b>DATOS DEL SOLICITANTE (en caso de no ser el propio paciente):<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name_sol elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name_sol\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre y apellidos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name_sol]\" id=\"form-field-name_sol\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-relation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-relation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[relation]\" id=\"form-field-relation\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f894e6f elementor-col-100\">\n\t\t\t\t\t<br>\n<b>DOCUMENTOS A SOLICITAR:<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-documents_sol elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-documents_sol\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t(Por favor, concretar si es necesario un informe de alta, urgencias... o el tipo de prueba a solicitar: ecograf\u00eda, RX, TAC, RM, Anal\u00edticas... especifica en la medida de lo posible las fechas)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[documents_sol]\" id=\"form-field-documents_sol\" rows=\"6\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-documentation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-documentation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDocumentaci\u00f3n identificativa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[documentation]\" id=\"form-field-documentation\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-accept_privacy elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[accept_privacy]\" id=\"form-field-accept_privacy\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-accept_privacy\">Ich habe die <a href=\"\/de\/aviso-legal\/\">Datenschutz-bestimmungen<\/a> gelesen und akzeptiere sie<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Senden<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0cf2fbc elementor-widget elementor-widget-text-editor\" data-id=\"0cf2fbc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Desde la entrega de este documento, y transcurridos 5 d\u00edas (h\u00e1biles) para copia de prueba y 10 d\u00edas (h\u00e1biles) para la copia de historias completas, puede venir a recoger la documentaci\u00f3n solicitada a recepci\u00f3n principal. Para la entrega de la documentaci\u00f3n ser\u00e1 necesario aportar la presente solicitud junto con el DNI y, si procede, la documentaci\u00f3n que se especifica en el APARTADO ACREDITACIONES. Se abonar\u00e1 por adelantado 5 euros por CD y 7 euros por placa. En caso de no recogerse en los dos meses siguientes a la solicitud, dicha copia ser\u00e1 destruida.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-62acfee\" data-id=\"62acfee\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-c0ea534 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c0ea534\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-4d7d15d\" data-id=\"4d7d15d\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6510d2c elementor-widget elementor-widget-text-editor\" data-id=\"6510d2c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">Acreditaci\u00f3n necesaria gesti\u00f3n documentaci\u00f3n cl\u00ednica<\/p><p style=\"text-align: justify;\"><strong>1. SI ES EL PROPIO PACIENTE QUI\u00c9N LA SOLICITA<\/strong><\/p><p style=\"text-align: justify;\">El d\u00eda de recogida de la documentaci\u00f3n deber\u00e1 acreditar su identidad por medio del original del DNI o pasaporte, junto con el impreso de solicitud de documentaci\u00f3n cl\u00ednica, correctamente cumplimentado.<\/p><p style=\"text-align: justify;\"><strong>2. SI ES PERSONA AUTORIZADA POR EL PROPIO PACIENTE<\/strong><\/p><p style=\"text-align: justify;\">Cumplimentar la autorizaci\u00f3n que consta en el mismo impreso o bien realizar una carta de autorizaci\u00f3n o de representaci\u00f3n firmada por el paciente, que incluya el nombre completo de la persona autorizada. (Adjuntaremos fotocopia a la solicitud). Tambi\u00e9n adjuntaremos copia del DNI o pasaporte del paciente y del DNI o pasaporte de la persona autorizada.<\/p><p style=\"text-align: justify;\">El d\u00eda de recogida de la documentaci\u00f3n deber\u00e1 aportar el original del DNI o pasaporte del paciente y el original del DNI o pasaporte de la persona autorizada.<\/p><p style=\"text-align: justify;\"><strong>3. PADRE O MADRE, EN CASO DE MENORES DE 16 A\u00d1OS.<\/strong><\/p><p style=\"text-align: justify;\">Adjuntaremos copia a la solicitud del DNI o pasaporte del solicitante y el Libro de familia.<\/p><p style=\"text-align: justify;\">El d\u00eda de recogida de la documentaci\u00f3n se deber\u00e1 aportar el original del DNI o pasaporte del solicitante. (Adjuntaremos fotocopia a la solicitud) y el Libro de familia (adjuntaremos fotocopia a la solicitud).<\/p><p style=\"text-align: justify;\"><strong>4. TUTOR LEGAL DEL PACIENTE.<\/strong><\/p><p style=\"text-align: justify;\">Adjuntaremos copia a la solicitud del documento acreditativo de la designaci\u00f3n judicial del tutor. Original del DNI o pasaporte del tutor. Original del DNI o pasaporte del tutor y original del DNI o pasaporte del tutelado.<\/p><p style=\"text-align: justify;\">En la recogida ser\u00e1 necesario documento acreditativo de la designaci\u00f3n judicial del tutor. Original del DNI o pasaporte del tutor. y original del DNI o pasaporte del tutelado.<\/p><p style=\"text-align: justify;\"><strong>5. DIFUNTO<\/strong><\/p><p style=\"text-align: justify;\">Adjuntaremos copia a la solicitud copia del DNI o pasaporte del difunto, copia DNI o pasaporte del solicitante. Copia de documentaci\u00f3n acreditativa de la vinculaci\u00f3n familiar directa o tercero legitimado. En caso de que la defunci\u00f3n no se haya producido en la Cl\u00ednica, se debe aportar el certificado de defunci\u00f3n.<\/p><p>\u00a0<\/p><p style=\"text-align: justify;\">*Todo ello dando cumplimiento por parte de esta cl\u00ednica a la Ley 41\/2002, de 14 de noviembre, b\u00e1sica reguladora de la autonom\u00eda del paciente y de derechos y obligaciones en materia de informaci\u00f3n y documentaci\u00f3n cl\u00ednica. Y al REGLAMENTO (UE) 2016\/679 DEL PARLAMENTO EUROPEO Y DEL CONSEJO de 27 de abril de 2016 relativo a la protecci\u00f3n de las personas f\u00edsicas en lo que respecta al tratamiento de datos personales y a la libre circulaci\u00f3n de estos datos y por el que se deroga la Directiva 95\/46\/CE (Reglamento general de protecci\u00f3n de datos) y a la Ley Org\u00e1nica 3\/2018, de 5 de diciembre, de Protecci\u00f3n de Datos Personales y garant\u00eda de los derechos digitales.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Impreso de solicitud de documentaci\u00f3n cl\u00ednica Desde la entrega de este documento, y transcurridos 5 d\u00edas (h\u00e1biles) para copia de prueba y 10 d\u00edas (h\u00e1biles) para la copia de historias completas, puede venir a recoger la documentaci\u00f3n solicitada a recepci\u00f3n principal. Para la entrega de la documentaci\u00f3n ser\u00e1 necesario aportar la presente solicitud junto con [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-15621","page","type-page","status-publish","hentry"],"acf":[],"featured_image_urls":{},"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/pages\/15621","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/comments?post=15621"}],"version-history":[{"count":0,"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/pages\/15621\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.grupopoliclinica.es\/de\/wp-json\/wp\/v2\/media?parent=15621"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}