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Request for access

Request for Access to Medical History

PATIENT
REPRESENTATIVE (only in case of representation, disability, or unemancipated minors under 14 years of age):

The legal representative declares on his own responsibility that, at the date of this request, there is no circumstance which may affect the validity of the supporting documentation submitted concerning the legal representation of the interested party.

Likewise, in the event that the exercise of the right has been carried out by one of the minor's parents, he/she declares that he/she is acting within the ordinary exercise of parental authority, always with the knowledge and consent of the other parent, in accordance with the provisions of Article 156 of the Civil Code.

PREFERRED NOTIFICATION CHANNEL
I EXPOSE

I wish to exercise my right of access to certain data, pursuant to Article 15 of Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016, Article 13 of Organic Law 3/2018 of 5 December on the protection of personal data and guarantee of digital rights, and Article 18 of Law 41/2002 of 14 November, regulating patient autonomy and rights and obligations in relation to clinical information and documentation.

I REQUEST

That I am provided with information relating to the processing of personal data to which I have the right of access within one month of the date of registration of this request.

Period
ATTACHED DOCUMENTATION
INSTRUCTIONS

Write in capitals.

  1. If the application is made by a representative, all the patient's details must be entered in the corresponding section (‘Patient’).
    1. Parent: natural person who exercises parental authority. If the request is submitted by a parent, proof of this status must be provided by presenting the corresponding document. In accordance with Article 156 of the Civil Code, with regard to third parties acting in good faith, it is presumed that each parent acts in the ordinary exercise of parental authority with the consent of the other.
      *A copy of both sides of the patient's parent's national identity card must be attached, as well as documentation proving this option. All personal documentation provided must be valid.
    2. Legal guardian:natural person who exercises guardianship over a minor or incapacitated person. If the application is submitted through a legal guardian, this status must be proven and the document justifying it must be provided.
      *A copy of both sides of the patient's parent's national identity card must be attached, as well as documentation proving this option. All personal documentation provided must be valid.
    3. Representative: Anyone acting as a representative must prove the capacity in which they are acting by any means valid in law that provides reliable evidence of this circumstance. 
      *A copy of both sides of the patient's parent's national identity card must be attached, as well as documentation proving this option. All personal documentation provided must be valid.

  2. A copy of the patient's identity card must be provided, and in the case of a representative, a copy of the identity card of the parent, legal guardian or representative. All personal documentation provided must be valid.

CLINICA VILAPARC, S.L.U. is the Data Controller of the user’s personal data and informs the user that these data will be processed in accordance with the provisions of Regulation (EU) 2016/679, of 27 April (GDPR), and Organic Law 3/2018, of 5 December (LOPDGDD), for which the following information on the processing is provided: 
Purposes and legitimacy of the processing: to maintain a commercial relationship (for the legitimate interest of the controller, art. 6.1.f GDPR) and to send communications about products or services (by consent of the data subject, art. 6.1.a GDPR). 
Data retention criteria: data will be kept for no longer than necessary to maintain the purpose of the processing or as long as there are legal requirements that dictate its custody and when it is no longer necessary to do so, it will be deleted with appropriate security measures to guarantee the anonymisation of the data or the total destruction of the same. 
Communication of data: If necessary for the development and execution of the purposes of the processing, we may transfer the data to our providers of services related to communications and IT, with which the RESPONSIBLE PARTY has signed the confidentiality and data processor agreements required by current privacy regulations. The data will also be provided to other companies of the Policlínica Group (Policlínica Ntra. Sra. del Rosario, S.L.U., Clínica Vilaparc, S.L.U., Eiviconsulta, S.L.U. and Clínica Premium Ibiza, S.L.U.), with the user’s consent, for the same purposes. 
User’s rights: the right to withdraw consent at any time. Right of access, rectification, portability and deletion of your data, and of limitation or opposition to its processing. The right to lodge a complaint with the Supervisory Authority (www.aepd.es) if you consider that the processing does not comply with the regulations in force. 
Contact details to exercise your rights: lopd@grupopoliclinica.es. Contact details of the Data Protection Officer: dpd@grupopoliclinica.es

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Clínica Vila Parc
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