About you
Your insurances
Note: Some insurance companies use the AHV or policy number as the insured person number.
Doctors and medical contacts
To keep the form clear, we only use the masculine form here.
Please give us your legal consents
With this transmission...
...I agree that the medical invoices are sent electronically encrypted via MediData (Tiers payant) directly to my health insurers. Upon request, a copy of the invoice will be sent to me
... I grant permission to forward the data required for invoicing as well as reports and findings to insurance companies (supplementary insurance, life insurance, social insurance, legal protection insurance), debt collection agents, lawyers, medical laboratories and other medical service providers (e.g. specialist institutes) as well as to government bodies, if necessary.
... I authorise the Diagnostic and Therapeutic Heart Centre AG to request medical records of previous, case-relevant treatments about me for inspection and to forward the medical results to the general practitioner, the referring physician and subsequent physicians. I agree that my attending physician may share my reports with a deputy physician of Diagnostisches und therapeutisches Herzzentrum AG.
...I agree that by processing my data at the Heart Centre, IT or medical technology service providers may view my data if necessary in the event of a malfunction, maintenance or support request.
... I declare that I have truthfully completed, acknowledged and understood the information in this form and agree to it.