Medical records request form

Compilando il presente formulario è possibile richiedere i dati di accesso all’App Insieme, per sé stessi oppure per una persona rappresentata (autorità parentale/tutela legale).

Paziente/richiedente

* Mandatory fields

* Name

* Last name

* Date of birth

* Upload your ID

Upload only PDF documents, maximum 15 MB

* Upload your ID

Upload only PDF documents, maximum 15 MB

* For each of the indicated treatment periods I wish to receive

(only one possible option)

Type 1 request (free of charge) – one or more specific documents Request one or more specific documents (e.g., an electrocardiogram or discharge letter). Please specify in the field below the exact information needed to help identify the documents.

Type 2 request (free of charge) – clinical and paraclinical elements of the medical record Includes a complete collection of key information about the care pathway, such as discharge reports, visits, exams, etc. All documents for this type of request are also readily available for download via the "Together EOC" application.

Type 3 request (may incur costs) – all medical and nursing documentation Apply only if necessary; provides access to the entire care pathway. May incur a cost of up to CHF 300 for complex administrative work.

Indicate the name of the person authorized to collect the documentation

* E-mail for receiving electronic documentation

* Indicate the date of the visit/recovery

* Indicate any additional date of the visit/recovery

* Protection of personal data

I declare that I have read, understood, and accept the information contained in the EOC Data Protection Statement.
I agree that my personal data, including health-related and other data worthy of special protection under Article 5 of the Federal Data Protection Act (DPA), will be processed and stored in accordance with this Declaration and the applicable data protection regulations in Switzerland.

By submitting this form, I declare that the information and documents provided are true. I am aware that in case of false statements or forged documents, I may incur penalties under Swiss law.

Informazioni da considerare per la richiesta

I dati inseriti verranno verificati con quelli già presenti nei nostri sistemi. In caso di corrispondenza, le credenziali di accesso verranno inviate al domicilio. Qualora i dati non risultassero coincidenti, non sarà possibile procedere con la richiesta. In tal caso, sarà necessario recarsi personalmente presso uno degli ospedali EOC per aggiornare i propri dati anagrafici e ricevere il foglio contenente le credenziali di accesso.

disclosure

Data Protection

EOC processes users' personal data in accordance with the Data Protection Law of the Canton of Ticino ("LPDP", RL 1.6.1.1.) and its Implementing Regulations. Click here to view our data protection notice.

Patients

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Medical records request form

Paziente/richiedente

Informazioni da considerare per la richiesta

Data Protection

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Medical records request form

Paziente/richiedente

Informazioni da considerare per la richiesta

Data Protection

How can we help you?

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