{"id":3775,"date":"2020-10-12T21:07:55","date_gmt":"2020-10-13T02:07:55","guid":{"rendered":"http:\/\/www.childrenscvm.com\/medical-record-release\/"},"modified":"2021-03-30T14:55:22","modified_gmt":"2021-03-30T19:55:22","slug":"solicitud-registros-medicos","status":"publish","type":"page","link":"https:\/\/www.childrenscvm.com\/es\/solicitud-registros-medicos\/","title":{"rendered":"Solicitud de Registros M\u00e9dicos"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3775\" class=\"elementor elementor-3775 elementor-3443\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d7a81ea elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d7a81ea\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-771c221\" data-id=\"771c221\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a0b9460 elementor-widget elementor-widget-shortcode\" data-id=\"a0b9460\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f4886-o1\" lang=\"es-ES\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/3775#wpcf7-f4886-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4886\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.4.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4886-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"form-row\">\n<div class=\"col-12\">\n<h5 class=\"text-transform\">Authorization to release medical record information <\/h5>\n<p><br\/>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre*<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombre\"><input type=\"text\" name=\"nombre\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Apellido*<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap apellido\"><input type=\"text\" name=\"apellido\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellido\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Fecha de Nacimiento*<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechanacimiento\"><input type=\"date\" name=\"fechanacimiento\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de Nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fecha de nacimiento*<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap numsegurosocial\"><input type=\"number\" name=\"numsegurosocial\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5 class=\"mb-4\">I authorize Childrens Cardiviovascular Medicine to realease my medial record to:<\/h5>\n<p><br\/>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreAutorizado\"><input type=\"text\" name=\"nombreAutorizado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Direcci\u00f3n*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap addressAutorizado\"><input type=\"text\" name=\"addressAutorizado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Ciudad*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap cityAutorizado\"><input type=\"text\" name=\"cityAutorizado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Estado*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap stateAutorizado\"><input type=\"text\" name=\"stateAutorizado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">C\u00f3digo postal*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap zipAutorizado\"><input type=\"text\" name=\"zipAutorizado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"C\u00f3digo postal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputPassword4\">Tel\u00e9fono*<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telAutorizado\"><input type=\"number\" name=\"telAutorizado\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputPassword4\">Fax<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap faxAutorizado\"><input type=\"number\" name=\"faxAutorizado\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Fax\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>I authorize Childrens Cardiovascular Medicine to release my medical records to:<\/h5>\n<h6 class=\"mb-4\">All medical sources, including any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medial facility, or other health care provider that has provided payment, treatment or services to me or on my behalf<\/h6>\n<p><br\/>\n    <\/div>\n<div class=\"col-12\">\n<h5>Please release the following documentation:<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <span class=\"wpcf7-form-control-wrap pleaserealese\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"Complete Chart\" \/><span class=\"wpcf7-list-item-label\">Complete Chart<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"Discharge summaries\" \/><span class=\"wpcf7-list-item-label\">Discharge summaries<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"Consultations\" \/><span class=\"wpcf7-list-item-label\">Consultations<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"Lab Work\" \/><span class=\"wpcf7-list-item-label\">Lab Work<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"X-Rays\" \/><span class=\"wpcf7-list-item-label\">X-Rays<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pleaserealese[]\" value=\"Skin test Other\" \/><span class=\"wpcf7-list-item-label\">Skin test Other<\/span><\/span><\/span><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">  Other:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap otherfollowing\"><input type=\"text\" name=\"otherfollowing\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other\" \/><\/span>\n    <\/div>\n<div class=\"w-100\"><\/div>\n<div class=\"col-12\">\n<h6 class=\"mb-4\">This authorization,as may be. applicable, extends to any medical records covered by any privilege, including without limitation to psychiatric, psychological and mental and records; records relating to drug treatment and\/or substance abuse; records related to sexually transmitted diseases and\/or social service notes.<\/h6>\n<p><br\/>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Firma del Paciente*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap patientAuthorization\"><input type=\"text\" name=\"patientAuthorization\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre Completo\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Date*:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap dateAuthorization\"><input type=\"date\" name=\"dateAuthorization\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5> Authorization expires one year after it is. signed:<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n<p>    <label for=\"inputEmail4\">First request:<\/label><br \/>\n         <span class=\"wpcf7-form-control-wrap request\"><select name=\"request\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"First request\">First request<\/option><option value=\"Second request\">Second request<\/option><option value=\"Third request\">Third request<\/option><\/select><\/span>\n    <\/div>\n<div class=\"form-group col-12\">\n<p><span class=\"wpcf7-form-control-wrap acceptance-375\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-375\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Acepto t\u00e9rminos y condiciones<\/span><\/label><\/span><\/span><\/span>\n    <\/p><\/div>\n<\/div>\n<p><input type=\"submit\" value=\"Enviar\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3775"}],"collection":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/comments?post=3775"}],"version-history":[{"count":3,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3775\/revisions"}],"predecessor-version":[{"id":4887,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3775\/revisions\/4887"}],"wp:attachment":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/media?parent=3775"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}