{"id":15620,"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":"2023-11-29T14:21:34","modified_gmt":"2023-11-29T12:21:34","slug":"impreso-de-solicitud-de-documentacion-clinica","status":"publish","type":"page","link":"https:\/\/www.grupopoliclinica.es\/en\/impreso-de-solicitud-de-documentacion-clinica\/","title":{"rendered":"CLINICAL DOCUMENTATION REQUEST FORM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15620\" class=\"elementor elementor-15620 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\">CLINICAL DOCUMENTATION REQUEST FORM <\/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=\"en_solicitud_documentacion_clinica\" name=\"EN Impreso de solicitud de documentaci\u00f3n cl\u00ednica\" aria-label=\"EN Impreso de solicitud de documentaci\u00f3n cl\u00ednica\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"15620\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3714d56\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"CLINICAL DOCUMENTATION REQUEST FORM - Grupo Policl\u00ednica\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"15620\"\/>\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>PATIENT DATA:<\/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\tName and surname(s)\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\tDate of birth \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\tID N\u00ba\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\tContact telephone number (mobile or landline)\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=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\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>APPLICANT DATA (if not the patient):<\/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\tName and Surname(s)\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\tRelationship with the patient\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>DOCUMENTS REQUESTED:<\/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(Please specify if a discharge report, emergency report\u2026 or the type of test requested: ultrasound, X-ray, CAT scan, MRI, analytical tests\u2026 specify the dates as best as possible).\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\tIdentification documentation\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\">I have read and accept the <a href=\"\/en\/aviso-legal\/\">Privacy Policy<\/a><\/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\">Send<\/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>From the date of submitting this document, and after 5 (working) days for proof copies and 10 (working) days for copies of complete histories, you can come and collect the requested documentation at the main reception desk. To collect the documents, you will need to present this application form together with your ID card and, if applicable, the documents listed in the PROOF OF ID section. An advance payment of \u20ac5 per CD and \u20ac7 per imaging film will be required. If the copy is not collected within two months of the application, it will be destroyed.<\/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;\"><strong>Proof of ID required for clinical documentation management<\/strong><\/p><ol><li><strong> IF YOU ARE THE PATIENT REQUESTING THE DOCUMENTATION<\/strong><\/li><\/ol><p>When you come to collect your documents, you must prove your identity with the original of your ID card or passport and the duly completed Clinical Documentation Request Form.<\/p><ol start=\"2\"><li><strong> IF YOU HAVE BEEN AUTHORISED BY THE PATIENT<\/strong><\/li><\/ol><p>Complete the authorisation on the same form or complete a letter of authorisation or representation signed by the patient, including the full name of the authorised person (a photocopy should be included with the application). Also enclose a copy of the patient&#8217;s ID card or passport and a copy of the identity card or passport of the authorised person.<\/p><p>When you come to collect your documents, you must present the original of the patient&#8217;s ID card or passport and the original of the authorised person&#8217;s ID card or passport.<\/p><ol start=\"3\"><li><strong> IF YOU ARE THE PARENT, IN THE CASE OF CHILDREN UNDER 16 YEARS OF AGE<\/strong><\/li><\/ol><p>Attach a copy of the applicant&#8217;s ID card or passport and family register (<em>Libro de Familia<\/em>) to the application.<\/p><p>When you come to collect your documents, you will need to present the original of the applicant&#8217;s ID card or passport (a photocopy must be attached to the application) as well as the family register (a photocopy must be attached to the application).<\/p><ol start=\"4\"><li><strong> IF YOU ARE THE PATIENT\u2019S LEGAL GUARDIAN<\/strong><\/li><\/ol><p>Attach a copy of the document confirming the judicial appointment of legal guardianship to the application. The guardian\u2019s original ID card or passport and original ID card or passport of the patient.<\/p><p>To collect the documents, you will need a document confirming the judicial appointment of legal guardianship. The guardian\u2019s original ID card or passport and original ID card or passport of the patient<\/p><ol start=\"5\"><li><strong> DECEASED<\/strong><\/li><\/ol><p>Attach copy of the ID card or passport of the deceased and a copy of the ID card or passport of the applicant to the application. A copy of a document certifying the direct family relationship or that of a legitimate third party. If the death did not occur at the Clinic, the death certificate must be provided.<\/p><p>* This is all in compliance with Law 41\/2002, of 14 November, the basic law regulating patient autonomy and rights and obligations regarding clinical information and documentation. And REGULATION (EU) 2016\/679 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95\/46\/EC (General Data Protection Regulation) and Organic Law 3\/2018, of 5 December, on the Protection of Personal Data and the Guarantee of Digital Rights.<\/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>CLINICAL DOCUMENTATION REQUEST FORM From the date of submitting this document, and after 5 (working) days for proof copies and 10 (working) days for copies of complete histories, you can come and collect the requested documentation at the main reception desk. To collect the documents, you will need to present this application form together with [&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":"full-width-container","site-content-style":"unboxed","site-sidebar-style":"unboxed","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":"set","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-15620","page","type-page","status-publish","hentry"],"acf":[],"featured_image_urls":{},"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/pages\/15620","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/comments?post=15620"}],"version-history":[{"count":0,"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/pages\/15620\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.grupopoliclinica.es\/en\/wp-json\/wp\/v2\/media?parent=15620"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}