Medical History Request Form Template for Switzerland

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Key Requirements PROMPT example:

Medical History Request Form

I need a Medical History Request Form compliant with Swiss regulations for a multi-location medical practice in Zurich, allowing for both electronic and paper-based record requests, with specific provisions for urgent care situations and cross-cantonal transfers.

Document background

The Medical History Request Form is a crucial document used in the Swiss healthcare system to facilitate the authorized transfer of patient medical records between healthcare providers, institutions, or to patients themselves. This form becomes necessary when medical history information needs to be shared for purposes such as continuing care, seeking second opinions, insurance claims, or legal proceedings. It must comply with strict Swiss data protection laws, including the Federal Act on Data Protection (FADP) and relevant cantonal regulations. The document includes specific provisions for patient consent, data protection notices, and authentication requirements, ensuring that sensitive medical information is handled appropriately and securely. The form is designed to be comprehensive yet clear, allowing for efficient processing while maintaining the high standards of Swiss healthcare privacy requirements.

Suggested Sections

1. Patient Information: Essential personal details including full name, date of birth, address, contact information, and insurance details

2. Request Authorization: Declaration of who is requesting the medical history (patient themselves, authorized representative, or healthcare provider) with verification details

3. Scope of Request: Specific medical information being requested, including time period and types of records

4. Purpose of Request: Clear statement of why the medical history is being requested (e.g., continuing treatment, second opinion, insurance purposes)

5. Healthcare Provider Details: Information about the healthcare providers from whom records are being requested

6. Data Protection Notice: Information about how the requested data will be handled, stored, and protected in compliance with Swiss law

7. Consent Declaration: Explicit patient consent for the release of medical information, including specific mentions of sensitive data categories

8. Authentication: Space for signature, date, and any required witness or notary confirmations

Optional Sections

1. Urgent Request Designation: Additional section to be included when the medical history is needed urgently, specifying reasons and required timeframe

2. Third Party Authorization: To be included when someone other than the patient is authorized to request or receive the medical history

3. Research Consent: Optional section for cases where the medical history might also be used for research purposes, requiring additional specific consent

4. International Transfer Notice: Required when medical history might be transferred outside Switzerland, including additional data protection information

5. Insurance Company Authorization: Specific section for insurance-related requests, including relevant policy numbers and coverage details

Suggested Schedules

1. List of Required Documents: Checklist of specific medical documents being requested (e.g., consultation notes, test results, imaging reports)

2. Identity Verification Documents: List of acceptable identification documents and requirements for authentication

3. Fee Schedule: Information about any applicable fees for requesting and processing medical records

4. Provider Contact List: Contact details and submission instructions for relevant healthcare providers

5. Privacy Policy: Detailed information about data protection measures and patient rights under Swiss law

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Medical Research

Healthcare Administration

Legal Services

Data Protection

Medical Records Management

Clinical Research

Pharmaceutical

Relevant Teams

Medical Records

Compliance

Legal

Patient Services

Healthcare Administration

Data Protection

Clinical Operations

Insurance Processing

Quality Assurance

Medical Information

Relevant Roles

Medical Records Administrator

Healthcare Privacy Officer

Compliance Manager

Medical Secretary

Clinical Administrator

Healthcare Provider

Medical Director

Insurance Claims Manager

Legal Counsel

Data Protection Officer

Patient Services Coordinator

Clinical Research Coordinator

Healthcare Operations Manager

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