Medical records request form for a family member


* Mandatory fields

* Upload patient ID

Upload only PDF documents, maximum 12 MB

* Legal Representative

Only one possible choice

It is mandatory to upload the ARP decision or release from medical confidentiality signed by the patient

Upload only PDF documents, maximum 12 MB

* I request copies of medical records related to

* Location(s) where the visit/recovery took place

(multiple options possible)

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

(only one possible option)

* Delivery details

(only one possible option)

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.

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.