Jules Bordet Institute | Mediation of Patients’ Rights

Mediation of Patients'Rights
(Contact form)

Brussels University Hospital – HUB

Please complete the form as precisely as possible so that the mediation request can be dealt with quickly and effectively.
In submitting this form you agree to the information provided being used by the Brussels University Hospital (HUB) to process your request, in accordance with the site’s confidentiality policy.

The information given below is transferred automatically to our hospital’s Mediation Service.
(*) = Required Field

Site concerned by the facts (*):

Erasmus Hospital

HUDERF – Queen Fabiola Children’s University Hospital

Jules Bordet Institute

CTR – Trauma and Rehabilitation Centre

CRG – Geriatric Rehabilitation Centre

Lothier Polyclinic

YOURS DETAILS:

Last name (*) :

First name(s) (*) :

Date of birth (*) :

Telephone (*) :

Email (*) :

Patient’s file no. :

Are you the patient concerned by the facts ? (*)

Yes

If no, please give the patient’s name + date of birth

Is the patient in agreement with the steps you are taking ?

Yes

I have not informed the patient

The patient or patient’s representative will be contacted to obtain their permission.

COMPLAINT :

Date and department concerned (*) :

Subject of the complaint(*) :

Reasons for the complaint (*) :

Patients’ Rights (see below)

Complaint not related to Patients’ Rights (see below)

Description of reasons for dissatisfaction
You may be dissatisfied with the service received at the hospital, in which case the Mediation Service is there to hear your comments. Please express yourself clearly and correctly. It serves no purpose to show any lack of respect for the mediator when expressing your dissatisfaction.

Identity of care staff called into question (*) :

A) COMPLAINT RELATING TO PATIENT RIGHTS

The right to benefit from a service of quality care in terms of :

a - Technical competence

b - Relations with the healthcare professional

c - Organisation within the patient care pathway

The free choice of professional practitioner

The right to be informed

a. about one’s state of health

b. about the financial repercussions of the intervention by the healthcare professional

Free consent to the healthcare, with information in advance

The right to be informed about the practitioner’s insurance and authorisation to practice the profession

Up-to-date medical files, which can be consulted and copies of which can be obtained

Guaranteed protection of private life

The right to receive from healthcare professionals the most appropriate care aimed at preventing, taking into account, treating and relieving pain while being attentive to what the patient has to say.

Other

If other, please detail :

B) COMPLAINTS NOT RELATED TO PATIENTS' RIGHTS

Logistics: comfort, meals, access, parking, cleanliness and hygiene, directions

Invoicing: estimation of costs, invoice, collection, payment plan, penalties

Administrative : admission, discharge, making appointments, visits

Language complaint

Attitude of staff: interview, technical, social welfare service, reception, security

Theft or loss of personal belongings

Fall, accident

Other

If other, please detail :

Mediation of Patients'Rights (Contact form)

Brussels University Hospital – HUB

Mediation of Patients'Rights
(Contact form)