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 FORMULAR EXONERARE/AUTHORISATION FORM
(versiune printabila/printable version)


Declaratie/ Declaration

Subsemnatul,…………………………... sunt de acord cu urmatoarele:

I,…………………………………….. accept that:

APRIL sa ceara informatii medicale de la medicii curanti referitoare la orice patologie, inclusiv boli psihiatrice, de dependenta de agenti chimici sau/ si in legatura cu SIDA

APRIL ask to the treating doctors for any medical information concerning any pathologies, including mental/ psychiatric health and / or chemical dependency and /or AIDS related

Autorizez orice medic curant sa furnizeze aceste informatii catre APRIL si ii exonerez de secretul profesional referitor la aceste informatii

I authorize any treating doctor to release such information to APRIL and I delivered the treating doctors from the professional secrecy.

Autorizez APRIL sa transmita aceste informatii societatii de asigurare si persoanelor autorizate sa se ocupe de acest caz.

I further authorize APRIL to release such information to the underwriter / insurer and to the officers, professionals or persons on duty for the management care

Autorizez APRIL sa ceara si sa obtina in numele meu si autorizez acest spital sa elibereze fisa medicala din perioada internarii mele in spital

I authorize APRIL to ask and obtain for me and I authorize this health care facility, to release my medical records for control purposes.

De acord,

Read and approved

Data si locul,

Date and place

Prezenta declaratie are valoare de autorizatie si exonerare de responsabilitate in fata legii.

The present declaration is valid as authorization and liability delivery in relation to the law.

De acord,

Read and approved

Data si locul,

Date and place

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