480 lines
25 KiB
HTML
480 lines
25 KiB
HTML
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xmlns:o="urn:schemas-microsoft-com:office:office"
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xmlns:w="urn:schemas-microsoft-com:office:word"
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xmlns:st1="urn:schemas-microsoft-com:office:smarttags"
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xmlns="http://www.w3.org/TR/REC-html40">
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<head>
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<meta http-equiv=Content-Type content="text/html; charset=windows-1252">
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<meta name=ProgId content=Word.Document>
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<meta name=Generator content="Microsoft Word 14">
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<meta name=Originator content="Microsoft Word 14">
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<link rel=File-List href="firmaAutorizacion_archivos/filelist.xml">
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<title>CONSENTIMIENTO INFORMADO F</title>
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<o:SmartTagType namespaceuri="urn:schemas-microsoft-com:office:smarttags"
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name="PersonName"/>
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<!--[if gte mso 9]><xml>
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<o:DocumentProperties>
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<o:Author>imq_smugueta</o:Author>
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<o:LastAuthor>Victor Atencia</o:LastAuthor>
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<o:Revision>2</o:Revision>
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<o:TotalTime>6</o:TotalTime>
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<o:Created>2012-12-11T09:58:00Z</o:Created>
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<o:LastSaved>2012-12-11T09:58:00Z</o:LastSaved>
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<o:Pages>1</o:Pages>
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<o:Words>283</o:Words>
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<o:Characters>1560</o:Characters>
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<o:Company>CSM</o:Company>
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<o:Lines>13</o:Lines>
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<o:Paragraphs>3</o:Paragraphs>
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<o:CharactersWithSpaces>1840</o:CharactersWithSpaces>
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<o:Version>14.00</o:Version>
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</o:DocumentProperties>
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<o:OfficeDocumentSettings>
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<o:TargetScreenSize>800x600</o:TargetScreenSize>
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</o:OfficeDocumentSettings>
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</xml><![endif]-->
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<link rel=themeData href="firmaAutorizacion_archivos/themedata.thmx">
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<link rel=colorSchemeMapping
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href="firmaAutorizacion_archivos/colorschememapping.xml">
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<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
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classid="clsid:38481807-CA0E-42D2-BF39-B33AF135CC4D" id=ieooui></object>
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<style>
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st1\:*{behavior:url(#ieooui) }
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<![endif]-->
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<style>
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<!--
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/* Font Definitions */
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@font-face
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{font-family:"Arial Narrow";
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panose-1:2 11 6 6 2 2 2 3 2 4;
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mso-generic-font-family:swiss;
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p.MsoNormal, li.MsoNormal, div.MsoNormal
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mso-style-qformat:yes;
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margin-bottom:.0001pt;
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p.MsoBodyText, li.MsoBodyText, div.MsoBodyText
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{mso-style-unhide:no;
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margin-bottom:.0001pt;
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text-align:justify;
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font-size:12.0pt;
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font-family:"Times New Roman","serif";
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mso-fareast-font-family:"Times New Roman";
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@page WordSection1
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{size:21.0cm 842.0pt;
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mso-footer-margin:36.0pt;
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mso-paper-source:7 0;}
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div.WordSection1
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<style>
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/* Style Definitions */
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table.MsoNormalTable
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{mso-style-name:"Tabla normal";
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mso-para-margin:0cm;
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mso-para-margin-bottom:.0001pt;
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mso-pagination:widow-orphan;
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font-size:10.0pt;
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font-family:"Times New Roman","serif";}
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<![endif]--><!--[if gte mso 9]><xml>
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<o:shapedefaults v:ext="edit" spidmax="1026"/>
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</head>
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<body lang=ES style='tab-interval:35.4pt'>
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<div class=WordSection1>
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<p class=MsoBodyText align=center style='margin-right:-1.3pt;text-align:center'><b><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'>CONSENTIMIENTO
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INFORMADO F</span></b><span style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'> <o:p></o:p></span></p>
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<p class=MsoNormal style='margin-right:-1.3pt;text-align:justify'><span
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style='font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>Por el presente documento quedo
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informado y consiento expresamente:<o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'> <o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>1. Que
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Cl�nica Arc�ngel San Miguel, S.A., Compa��a de Seguros Igualatorio M�dico
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Quir�rgico y de Especialidades de Navarra, S.A. (IMQ) y los laboratorios y
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personal facultativo del cuadro m�dico de IMQ, traten mis datos, incluidos los
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datos de salud, con la finalidad de mejorar la prestaci�n de los servicios
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sanitarios solicitados, en concreto, el de la creaci�n de un Historial M�dico
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�nico a trav�s del cual, cualquiera de los facultativos que me traten o puedan
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tratarme conozcan, de modo inmediato, toda la<span style='mso-spacerun:yes'>�
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</span>informaci�n cl�nica y pruebas diagn�sticas a las que me someta.<o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>2. Que
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mis datos personales junto con los de mi Historial M�dico contenido en la base
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de datos de Cl�nica Arc�ngel San Miguel, S.A, o en la base de datos de los
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facultativos del cuadro m�dico de IMQ, sea comunicado a IMQ, para su
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incorporaci�n a la base de datos denominada <i>�TARISAN IMQ�</i> con el fin de
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crear una �nica base de datos que contenga todo mi Historial M�dico con la
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finalidad mencionada anteriormente.<o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>En este sentido, los laboratorios y
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personal facultativo del cuadro m�dico de IMQ y cuya identificaci�n detallada
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se puede encontrar en <st1:PersonName ProductID="la P�gina Web" w:st="on">la
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P�gina Web</st1:PersonName> <b style='mso-bidi-font-weight:normal'>ww.imqnavarra.com</b>,
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podr�n tratar mis datos personales incluidos los datos de salud.<o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>3. Que podr�
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ejercitar mis derechos de acceso, rectificaci�n, oposici�n y cancelaci�n a
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trav�s de la direcci�n de correo electr�nico <b style='mso-bidi-font-weight:
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normal'>datosIMQ@imqnavarra.com</b>.<o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>4.<span style='mso-spacerun:yes'>�
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</span>Que las personas autorizadas para el tratamiento o acceso a mis datos
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personales en la base de datos denominada <i>�TARISAN IMQ�</i> ser�n los
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facultativos a los que haga entrega de mi tarjeta sanitaria.<o:p></o:p></span></p>
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<p class=MsoNormal style='margin-right:-1.3pt;text-align:justify'><span
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style='font-family:"Arial Narrow","sans-serif"'> <o:p></o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'>En Pamplona a </span><!--[if supportFields]><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-element:field-begin'></span><span
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style='mso-spacerun:yes'>�</span>TIME \@ "dd' de 'MMMM' de 'yyyy" <span
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style='mso-element:field-separator'></span></span><![endif]--><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-no-proof:yes'>____ de _____________ de _____</span></span><!--[if supportFields]><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-element:field-end'></span></span><![endif]--><span style='font-size:
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10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p></o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:-1.3pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p><span
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style='mso-no-proof:yes'>Nombre y apellidos:___________________________________</span></o:p></span></p>
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<p class=MsoBodyText style='margin-right:16.65pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:16.65pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText style='margin-right:16.65pt'><span style='font-size:10.0pt;
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font-family:"Arial Narrow","sans-serif"'> <o:p></o:p></span></p>
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<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
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style='border-collapse:collapse;mso-yfti-tbllook:1184;mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
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<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'>
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<td width=291 valign=top style='width:218.05pt;padding:0cm 5.4pt 0cm 5.4pt'>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><!--[if supportFields]><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-element:field-begin'></span><span
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style='mso-spacerun:yes'>�</span>MERGEFIELD BENEFICIARIO1 <span
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style='mso-element:field-separator'></span></span><![endif]-->
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><b
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style='mso-bidi-font-weight:normal'><span style='font-size:10.0pt;font-family:
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"Arial Narrow","sans-serif"'> <o:p></o:p></span></b></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><b
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style='mso-bidi-font-weight:normal'><span style='font-size:10.0pt;font-family:
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"Arial Narrow","sans-serif"'> <o:p></o:p></span></b></p>
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<span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-no-proof:yes'>Fdo:________________________</span></span><!--[if supportFields]><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><span
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style='mso-element:field-end'></span></span><![endif]--><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p></o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><b
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style='mso-bidi-font-weight:normal'><span style='font-size:10.0pt;font-family:
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"Arial Narrow","sans-serif"'>DNI:________________________<o:p></o:p></span></b></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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</td>
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<td width=283 valign=top style='width:212.6pt;padding:0cm 5.4pt 0cm 5.4pt'>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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</td>
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</tr>
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<tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'>
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<td width=291 valign=top style='width:218.05pt;padding:0cm 5.4pt 0cm 5.4pt'>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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</td>
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<td width=283 valign=top style='width:212.6pt;padding:0cm 5.4pt 0cm 5.4pt'>
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<p class=MsoBodyText align=left style='margin-right:16.65pt;text-align:left'><span
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style='font-size:10.0pt;font-family:"Arial Narrow","sans-serif"'><o:p> </o:p></span></p>
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</td>
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</tr>
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</table>
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<p class=MsoNormal><o:p> </o:p></p>
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</div>
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</body>
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</html>
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