REQUERIMENTO DE COPIA DE PRONTUARIO/ RELATORIO MEDICO
Eu, ebelxo identiicado, na qualidade de:
o Paciente
@Representanielegel (untar documentagSo! procuragso eepecfice)
‘Venho, solicitar a esta Insituigdo o fornecimento de:
Cépia do prontuério médico
1 Relatério médico do paciente abaixo especificado.
Outros:
Deciaro que:
'2) Estou clente que a cbpia do prontuérioficeré sob minha inteira responsabilidade, devendo menter em siglo as informagbes
confidenciais contidas, isentando esta Instituigso por quebra de segredo profissional,
by Tento conhecimento de que as despesas ficam sob responsablidade do solitante, devendo ser quitadas antes da execuro
das cbpias, cujes valores sero mensurados ep6s o desarquivamento do prontuério médica. Apés informados, o pagemento
devera ooorrer em perlodo no superior a___ horas e as obpias ser8o disponiblizadas pare retirada em até__dias
‘contados da remessa do comprovante de pagamento dos custos, permanecendo disponivel por__ dias. Apds esse
prazo as cépias serBo destruidas e 0 prontuario rearquivedo.
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