Form to request a copy of medical records

Form

Patient identity

If the patient is deceased and has not objected, only the spouse, legal or common-law partner, and relatives up to and including the second degree may request indirect access to the file, provided they submit a justified and reasoned request. This access may only be granted via a physician.

Name

First name

Date of birth

Email

Emails are only used to exchange information relating to the request, not to transfer a copy of the file.

Phone number

Address

City

Postal code

Country

Applicant's identity

(to be completed only if different from the patient: authorized individual, parent, guardian, legal representative, attorney, physician…)

Name

First name

Date of birth

Email

Emails are only used to exchange information relating to the request, not to transfer a copy of the file.

Phone number

Address

City

Postal code

Country

Recipient's identity

(to be completed only if distinct from the patient and/or the applicant)

Name

First name

Date of birth

Email

Emails are only used to exchange information relating to the request, not to transfer a copy of the file.

Phone number

Address

City

Postal code

Country

Precision about the demand

Copy

USB key sent by registered mail to the address provided

USB key to be collected from the Medical Department office on site

The accurate and comprehensive display of a copy on a digital medium necessitates that the recipient possesses a current Internet browser.

Place of Vivalia

Multiple boxes may be selected.

Hôpital Vivalia d'Arlon (CSL)

Hôpital Vivalia de Bertrix (CUP)

Hôpital Vivalia de Bastogne (CHCA effective 01/07/2021)

Hôpital Vivalia de Bastogne (formerly IFAC prior to 01/07/2021)

Hôpital Vivalia de Libramont (CHCA)

Hôpital Vivalia de Marche

Hôpital Vivalia de Virton (CSL)

Documents requested

Complete version of the document

Partial copy

Consultation and hospitalization letters

Medical imaging scans

Medical imaging protocols (X-rays, MRIs, ultrasounds, etc.)

Laboratory test results

Nursing records

Pharmaceutical prescriptions

Other

When you make a demand of partiel copy :

Period: from

Period: at

Specialty(ies)

Au-delà de trois spécialités, l'envoi se fait par défaut en copie complète.

Attached documents

Copy of identity card

1 seul fichier.
Limité à 700 Mo.
Types autorisés : gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Power of attorney signed by the patient

The applicant must attach to this request written proof of their right to request a copy of the patient's file (power of attorney signed by the patient, guardianship order, etc.).
1 seul fichier.
Limité à 700 Mo.
Types autorisés : txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Applicant's reasoned request

The applicant must include a justification for the request for indirect consultation of the deceased patient's medical file, and only if the latter did not object to it.
1 seul fichier.
Limité à 700 Mo.
Types autorisés : txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Form to download

en_-_copy_of_medical_records.pdf

Contacts by email

Direction médicale Vivalia Arlon : directionmedicale.csl@vivalia.be
Direction médicale Vivalia Bertrix : dmc@vivalia.be
Direction médicale Vivalia Bastogne/Libramont : demandedossier.chca@vivalia.be
Direction médicale Vivalia Marche : secretariat.direction.medicale.marche@vivalia.be

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Form

Patient identity

Applicant's identity

Recipient's identity

Precision about the demand

When you make a demand of partiel copy :

Attached documents

Form to download

en_-_copy_of_medical_records.pdf

Contacts by email

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