സ്വകാര്യ ആശുപത്രിയിലെ ചികിത്സാ രേഖകള്‍ക്കായി ആരോഗ്യ വകുപ്പില്‍ നല്‍കേണ്ട വിവരാവകാശ അപേക്ഷയുടെ മാതൃക. ചികിത്സാ രേഖകള്‍ക്കായി ഹോസ്പിറ്റലില്‍ നേരിട്ട് / തപാലില്‍ നല്‍കേണ്ട അപേക്ഷയുടെ മാതൃക താഴെയും കൊടുത്തിരിക്കുന്നു. വിവരാവകാശ നിയമപ്രകാരമുള്ള അപേക്ഷയില്‍, ആര്‍.ടി.ഐ ആക്റ്റ് സെക്ഷന്‍ 2(f) പ്രകാരം സ്വകാര്യ നികായത്തെ സംബന്ധിച്ച ക്ഷമതയുള്ള അധികാരകേന്ദ്രമായ ജില്ലാ മെഡിക്കല്‍ ഓഫീസര്‍ക്ക് പ്രാപ്യമായ വിവരങ്ങള്‍ ആണ് ആവശ്യപ്പെടുന്നത് എന്നും അവ ശേഖരിച്ച് നല്കുകയോ അല്ലെങ്കില്‍ വിവരങ്ങള്‍ അപേക്ഷകന് നല്‍കുവാന്‍ ബന്ധപ്പെട്ട ആശുപത്രിക്ക് നിര്‍ദേശം നല്കുകയോ ചെയ്യണമെന്ന് അപേക്ഷയില്‍ ബോധിപ്പിക്കേണ്ടതാണ്.
From
Name & address of the applicant
To
State Public Information Officer
District Medical Officer /Directorate of Health Services/Ministry of Health Department
<Address of the said Govt office>
Respected Sir,
Subject: RTI application seeking the treatment details from
............. Hospital, ................ within 48 hours as per section
7(1).
Reference: 1) Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, Section 1.3.2.
2) National Consumer Disputes Redressal Commission Judgment (NCDRC) regarding the medical records of a patient.
Reference: 1) Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, Section 1.3.2.
2) National Consumer Disputes Redressal Commission Judgment (NCDRC) regarding the medical records of a patient.
Name & address of the hospital: .............................
IP Number: .............................
Name of the patient: ...............................
Applicant's relationship with Patient: ...............
Date of Admission: ..........................
Date of Discharge: ..........................
IP Number: .............................
Name of the patient: ...............................
Applicant's relationship with Patient: ...............
Date of Admission: ..........................
Date of Discharge: ..........................
I was admitted in ........................ hospital during the above
period. I request you to take necessary steps to get complete
information about the treatment given to me during the above mentioned
period. I kindly request you to instruct the above hospital using the
power of the officer concerned to provide the below information as per
RTI act section 2(f). Please provide the requested information within 48
hours as it is related to life and liberty of a person.
Please provide the following information/copy of the documents:
1.Case sheet.
2. All investigation reports including radiology reports with film.
3. Medication charts.
4. Doctor's prescription sheets.
5. Daily progress notes
6. Treatments and procedure done by the hospital
7. Name and qualification of the doctors involved in each procedure.
8. Admission assessment papers.
9. All consent documents.
10. Referral letters received from other hospital(s) if any
11. Diet charts, Water intake output charts.
12. Complete case history/details about the previous admission of the patient.
13. Final Bill along with complete break up.
14. All follow up charts.
15. All other documents held with the hospital regarding the treatment
2. All investigation reports including radiology reports with film.
3. Medication charts.
4. Doctor's prescription sheets.
5. Daily progress notes
6. Treatments and procedure done by the hospital
7. Name and qualification of the doctors involved in each procedure.
8. Admission assessment papers.
9. All consent documents.
10. Referral letters received from other hospital(s) if any
11. Diet charts, Water intake output charts.
12. Complete case history/details about the previous admission of the patient.
13. Final Bill along with complete break up.
14. All follow up charts.
15. All other documents held with the hospital regarding the treatment
I kindly request you to consider this application with high priority
and please take immediate steps to get the information. I enclose copy
of my ............... for the proof of identity.
Place: Signature
Date:
Place: Signature
Date:
ചികിത്സാ രേഖകള്‍ക്കായി ഹോസ്പിറ്റലില്‍ നല്‍കേണ്ട അപേക്ഷയുടെ മാതൃക.
From
<Name of the applicant>
<Address with Pincode>
To
Director
<Name and Address of the hospital>
Respected Sir,
Subject: Application for treatment details / records.
Reference: 1) Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, Section 1.3.2.
2) National Consumer Disputes Redressal Commission Judgment (NCDRC) regarding the medical records of a patient.
Kind attention is invited to the reference cited. I was admitted in your hospital during the below mentioned period. I request you to provide complete information about the treatment given to me during these periods within 72 hours.
1) IP Number: .............................
Date of Admission: ..........................
Date of Discharge: ..........................
2) IP Number: .............................
Date of Admission: ..........................
Date of Discharge: ..........................
Please provide the following information / copy of the documents / records:
1. Case sheet.
2. All investigation reports including radiology reports with film.
3. Medication charts
4. Doctor's prescription sheets
5. Daily progress notes
6. Treatments and procedure done by the hospital
7. Name and qualification of the doctors involved in each procedure.
8. Admission assessment papers
9. All consent documents
10. Referral letters received from other hospital(s) if any
11. Diet charts, Water intake output charts
12. Complete case history / details about the previous admission of the patient.
13. Final Bill along with complete break up.
14. All follow up charts
15. All other documents held with the hospital regarding the treatment
I kindly request you to consider this application with high priority and please take immediate steps to provide all the details within 72 hours as specified in Indian Medical Council Regulations, 2002, Section 1.3.2.
Place: Yours faithfully,
Date:
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