Coordination request

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Your NephroCare Holiday Dialysis Coordination Team is looking forward to assist you! Group requests are also welcome.

Coordination Request Form

Please fill out the following fields below (* are mandatory) for a nonbinding coordination request. Our team will get back to you as soon as possible.

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Contact Information
Holiday Period
Destination

In order to determine availability for your initial, non-binding Holiday Dialysis coordination request all asked patient information is mandatory. Therefore, we kindly ask you to submit the information completely and correctly to the best of your knowledge.

After submitting your initial coordination request the provided information needs to be completed by submitting the full Holiday Dialysis coordination request form including a copy of blood serology test results. Any false information may lead to termination of given (pre-) confirmation.

Holiday Dialysis Coordination Patient Privacy Notice and Consent

What is this Holiday Dialysis Coordination Patient Privacy Notice about?
This Holiday Dialysis Coordination Patient Privacy Notice (“Notice”) explains how Fresenius Medical Care Italia S.p.A. located at Palazzo Pignano (CR), Via Crema 8, Italy (also “FME” or “We”) process your personal information, why and when. We are providing the service of Holiday Dialysis Coordination (“HDC”) for you. This Notice also describes your rights and how you can exercise them.

Who is the Data Controller for my information?
The data controller for your information used for HDC purposes is Fresenius Medical Care Italia S.p.A.

What information do We collect, use, transfer and disclose, and why?
In the course of HDC activity, we will collect information about you. In the annex you will find more specific information regarding what personal information We process and the purposes for which We process it.
Your personal information is necessary for us to provide you with HDC. Your refusal to provide your personal information in whole or in part may make it impossible for FME to coordinate your holiday dialysis treatment.

Who has access to your personal information (including cross-border transfers)?
We provide third parties or other entities of FME group with access to your personal information where this is necessary for   the purposes listed in the annex. This is always on a need to know basis. For a list of the categories of third parties, please  see the annex to this Notice.

These third parties are expected to protect the confidentiality and security of your personal information.
Due to the global nature of our HDC service, We may transfer your personal information outside your home country including  to countries that have a different data protection regime. If you are located in the European Economic Area (the "EEA") this  may include countries outside of the EEA. In case of cross border transfer, the transfer of the personal information is based on EU standard contractual clauses that impose equivalent data protection obligations directly on the recipient, on the consent included in this Notice or on other legal mechanisms that may be required in your country. A copy of the relevant mechanism can be provided for your review – see the contact us section for how to request this.

For how long do We keep your personal information?
After processing related to HDC, your personal information, including Medical Data, are stored for ten (10) years and subsequently erased. We do not keep the data you provide for HDC purposes deidentified for subsequent research and statistical purposes.

What are your rights?
You have the right to request a copy of your personal information, including health documentation and to request correction     of any information that is incomplete or inaccurate. You may also have the right to receive the personal information which you provided to us in an electronic format so that you can transmit or request us to transmit this to another company.
You can object to the processing of your personal information in some circumstances (in particular, where We don’t have to process the information to meet a contractual or other legal requirement). You can ask us to erase your information in some circumstances. In certain circumstances, you also have the right to request that We restrict the processing of your personal data for certain purposes. These rights can be limited – for example where we need your personal information (i) to comply  with the law or (ii) to protect your vital interests, or where providing your information would reveal personal data about another person. You can enforce any of the above rights by contacting us at contact details provided below.

How can I withdraw my consent?
If you give us consent to processing your personal information and Medical Data or transfer your personal information and Medical Data outside of the European Economic Area for HDC purposes, you can withdraw this consent at any time by contacting us at contact details provided below. Please note that withdrawal of consent does not affect the lawfulness of processing or transfer based on consent before its withdrawal.

Changes to this Notice
This Notice is effective as of 1st September 2019 and may be updated from time to time. We will notify you of material   changes to our Notice by sending you an email or through other means in which We may also seek your consent.

How to contact us?
For any concerns relating to data protection or in order to exercise your rights you may contact:            Privacyliason.italia@fmc-ag.com

ANNEX
Types of Personal Information We Process:
Personal Details: Includes your name, date of birth, gender, home address, phone number(s),
emergency contact details, race/ethnicity where this is relevant to your treatment.
Health insurance Data: Name of insurance provider, insurance specific patient codes and
reference numbers, invoicing data, validity date.
Medical Data: Includes medical information received from your home clinic for subsequent transfer
to holiday dialysis clinic, including:

  • blood test results and the results of other medical tests
  • information about your dialysis such as methods of access, prescription, temperature and time of treatment, medication administered and materials used (with LOT numbers), details of pressures, pumps, and any complications experienced
  • blood tests and the results of other medical tests, information about drug therapies, transplant status, vaccination status, infective status and allergies, examinations, transfusions, hospitalisation, comorbidities and prior treatments
  • information you provide about your health and well-being data

We obtain some of this information directly from you, some from the health professional who referred you and some from the home clinic or other healthcare institutions which are involved in your care and treatment.
The Purposes and Legal Bases for which We Process your Personal Information:

  • Where We have a contract to provide HDC, to fulfil this contract, or to take steps linked to the contract such as scheduling treatments or tracking the availability of dialysis stations at holiday dialysis clinics.
  • As required to conduct our business and pursue our legitimate interests, in particular managing complaints or claims.
  • With your consent, for the purpose of providing HDC services:
    • FME will process Medical Data received from you, from the health professional who referred you and from the home clinic or other healthcare institutions which are involved in your care and treatment.
    • FME will transfer your personal information and Medical Data to holiday dialysis units not belonging to FME network and located in countries that have a different data protection regime.

With whom do We share your personal information?
Third parties: To the extent permitted by applicable local provisions, with companies that provide products and services to  FME, such as for invoicing and auditing purpose or for IT support. Other providers or companies that are involved in delivering or funding your care and treatment - including laboratories, transport companies, transplant centers, health insurance companies, dialysis clinics and units either belonging or not to FME network.
Medical Personnel: such as clinical staff for treatment purposes and other medical personnel involved in your holiday dialysis treatment.
FME Personnel: such as Country Medical Directors, members of HDC centers worldwide, and first level support for EuCliD for the purposes of medical treatment and providing recommendations to medical personnel.
Acknowledgement and

Coordination of Holiday Dialysis Treatments - General Terms and Conditions

General Terms and Conditions

§ 1 Preamble
Fresenius Medical Care Italia S.p.A. (in the following “FMC”) operates the coordination centre based in Italy and is responsible for the supporting coordination of dialysis treatments at holiday destinations (in the following “Holiday Dialysis”) of a patient (“Patient”). The Patient wishes to receive dialysis treatments at one or more holiday destinations and asks FMC to coordinate such Holiday Dialysis for him.
Therefore, the Patient and FMC (both hereinafter also referred to as “Party” and together as “Parties“) enter into the following Agreement (in the following „Agreement“).

§ 2 Services of FMC

  1. FMC shall support the coordination of one or more dialysis treatments for the Patient at a center specialized in dialysis treatments identified by FMC in accordance with the criteria indicated by the Patient.
  2. The coordination of Holiday Dialysis includes the evaluation of availability of potential dialysis centers at the requested holiday destination in accordance with the criteria indicated by the Patient in terms of location, period of time and times and frequency of dialysis treatments („Availability Check“). That means, FMC coordinates the availability check request of the Patient in the name of the Patient at an available dialysis center selected by the Patient (in the following “Selected Dialysis Center”) and establishes contact between the Patient and the Selected Dialysis Center.
  3. For the sake of clarification, FMC only provides support to establish the initial contact between the Patient and the Selected Dialysis Center. The final decision and confirmation whether a treatment can be performed during the requested time by Patient is solely at the discretion of the Selected Dialyses Center. In the event of any unforeseen changes (e.g. the first Selected Dialyses Center by the Patient cannot perform the treatment for medical reasons), FMC will support the Patient by trying to establish a further contact with another potential Selected Dialyses Center. However, FMC does not guarantee any positive outcome regarding the realization of the request of the Patient in any way.
  4. The actual treatments are exclusively handled by the Selected Dialysis Center which is fully and exclusively responsible for the treatment. FMC is neither involved in the actual performance and legal compliance of such dialysis treatments nor in the booking or performance of the holiday trip.
  5. If and to the extent, according to the assessment of FMC, assistance or takeover of another coordination centre within the Fresenius Medical Care group of companies (in the following “Alternative Coordination Centre”) is required or helpful in context with organising a Holiday Dialysis in a successful and efficient way, FMC is entitled to involve such alternative coordination center. A list of coordination centers worldwide can be accessed here (https://www.nephrocare.com/patients-home/holiday-dialysis/booking-request.html). The Alternative Coordination Centers provide the same services as provided by FMC under this agreement as subcontractors of FMC.
  6. FMC will provide the above mentioned Services under this Agreement free of charge.

§ 3 Responsibilities of the Patient

  1. The Patient shall provide all personal information required to successfully coordinate the requested Holiday Dialysis. In particular, the Patient shall provide information on his intended holiday trip (destination and period of time) and the requested dialysis times and frequency.
  2. Furthermore, the Patient shall ensure and hereby provides authorization that the physician treating him at his home dialysis center (in the following “home physician”) will provide the Selected Dialysis Center with the required medical and health information as listed in the attached “Holiday Dialysis Request” as soon as possible before the date of the scheduled beginning of the Holiday Dialysis. FMC may assist the Patient by asking the home physician to complete the “Holiday Dialysis Request” and transferring the completed form to the Selected Dialysis Center or by asking the physician at the Selected Dialysis Center to access the data required via the electronic therapy information system “EuCliD 5”.
  3. The Patient shall return signed copies of this Agreement and the attached Consent Form as soon as possible before the date of the scheduled beginning of the Holiday Dialysis that is a prerequisite for FMC to duly start coordinating the requested Holiday Dialysis.
  4. The Parties agree that a holiday dialysis center may deny treatment of a particular Patient at any time during the process supported by FMC according to this Agreement, in particular, if a holiday dialysis center cannot provide the relevant resources required for a particular treatment.

§ 4 Term and Termination
This Agreement takes effect upon being duly signed by the Patient. This Agreement may be terminated by each Party at any time in written form.

§ 5 Liability
FMC is only fully liable for damage caused to the Patient by an intentional or grossly negligent breach of duty by its employees, statutory representatives or auxiliary persons employed to perform duties under this Agreement. Where a claim for damages against FMC is based on simple negligence on the part of FMC (including the persons listed above), FMC is liable only for
death, personal injury or damage to health or,
where the duty breached is an essential contractual obligation on compliance with which the Patient is usually and legitimately entitled to rely as a precondition for due performance of this Agreement, foreseeable damage typical of such contracts.

§ 6 Data Protection
The Patient notices that for the purpose of this Agreement it is necessary to provide and disclose personal data to FMC and  the physicians at the Selected Dialysis Center. The details of data processing operations in context with the coordination of Holiday Dialysis treatments are described in the attached Consent Form that is to be signed by the Patient.

§ 7 Miscellaneous

  1. This Agreement and the contractual relationship is governed by the laws of Italy. The statutory provisions to limit the choice of law and to apply mandatory provisions particularly of the state in which the Patient as a consumer has his habitual residence remain unaffected.
  2. Headlines in this Agreement are not relevant for the interpretation of the Agreement. Should provisions of this Agreement be or become invalid or unfeasible, the validity of the remaining provisions of this Agreement shall not be affected thereby. The parties are required to jointly replace the invalid or unfeasible provision with a valid provision approximating the invalid or unfeasible one as closely as possible. The same applies for any lacunae in this Agreement.
  3. There exist no ancillary verbal side-agreements to this Agreement. Any amendments of this Agreement must be in writing and must be signed by both parties. This does also apply to a change of this written form requirement. Unless legally required elsewhere, e-mail messages are not deemed to satisfy the written-form requirement.

 

Holiday Dialysis Coordination Patient Privacy Notice and Consent

What is this Holiday Dialysis Coordination Patient Privacy Notice about?
This Holiday Dialysis Coordination Patient Privacy Notice (“Notice”) explains how Fresenius Medical Care Italia S.p.A. located at Palazzo Pignano (CR), Via Crema 8, Italy (also “FME” or “We”) process your personal information, why and when. We are providing the service of Holiday Dialysis Coordination (“HDC”) for you. This Notice also describes your rights and how you can exercise them.

Who is the Data Controller for my information?
The data controller for your information used for HDC purposes is Fresenius Medical Care Italia S.p.A.

What information do We collect, use, transfer and disclose, and why?
In the course of HDC activity, we will collect information about you. In the annex you will find more specific information regarding what personal information We process and the purposes for which We process it.
Your personal information is necessary for us to provide you with HDC. Your refusal to provide your personal information in whole or in part may make it impossible for FME to coordinate your holiday dialysis treatment.

Who has access to your personal information (including cross-border transfers)?
We provide third parties or other entities of FME group with access to your personal information where this is necessary for   the purposes listed in the annex. This is always on a need to know basis. For a list of the categories of third parties, please  see the annex to this Notice.

These third parties are expected to protect the confidentiality and security of your personal information.
Due to the global nature of our HDC service, We may transfer your personal information outside your home country including  to countries that have a different data protection regime. If you are located in the European Economic Area (the "EEA") this  may include countries outside of the EEA. In case of cross border transfer, the transfer of the personal information is based on EU standard contractual clauses that impose equivalent data protection obligations directly on the recipient, on the consent included in this Notice or on other legal mechanisms that may be required in your country. A copy of the relevant mechanism can be provided for your review – see the contact us section for how to request this.

For how long do We keep your personal information?
After processing related to HDC, your personal information, including Medical Data, are stored for ten (10) years and subsequently erased. We do not keep the data you provide for HDC purposes deidentified for subsequent research and statistical purposes.

What are your rights?
You have the right to request a copy of your personal information, including health documentation and to request correction     of any information that is incomplete or inaccurate. You may also have the right to receive the personal information which you provided to us in an electronic format so that you can transmit or request us to transmit this to another company.
You can object to the processing of your personal information in some circumstances (in particular, where We don’t have to process the information to meet a contractual or other legal requirement). You can ask us to erase your information in some circumstances. In certain circumstances, you also have the right to request that We restrict the processing of your personal data for certain purposes. These rights can be limited – for example where we need your personal information (i) to comply  with the law or (ii) to protect your vital interests, or where providing your information would reveal personal data about another person. You can enforce any of the above rights by contacting us at contact details provided below.

How can I withdraw my consent?
If you give us consent to processing your personal information and Medical Data or transfer your personal information and Medical Data outside of the European Economic Area for HDC purposes, you can withdraw this consent at any time by contacting us at contact details provided below. Please note that withdrawal of consent does not affect the lawfulness of processing or transfer based on consent before its withdrawal.

Changes to this Notice
This Notice is effective as of 1st September 2019 and may be updated from time to time. We will notify you of material   changes to our Notice by sending you an email or through other means in which We may also seek your consent.

How to contact us?
For any concerns relating to data protection or in order to exercise your rights you may contact:            Privacyliason.italia@fmc-ag.com

ANNEX
Types of Personal Information We Process:
Personal Details: Includes your name, date of birth, gender, home address, phone number(s),
emergency contact details, race/ethnicity where this is relevant to your treatment.
Health insurance Data: Name of insurance provider, insurance specific patient codes and
reference numbers, invoicing data, validity date.
Medical Data: Includes medical information received from your home clinic for subsequent transfer
to holiday dialysis clinic, including:

  • blood test results and the results of other medical tests
  • information about your dialysis such as methods of access, prescription, temperature and time of treatment, medication administered and materials used (with LOT numbers), details of pressures, pumps, and any complications experienced
  • blood tests and the results of other medical tests, information about drug therapies, transplant status, vaccination status, infective status and allergies, examinations, transfusions, hospitalisation, comorbidities and prior treatments
  • information you provide about your health and well-being data

We obtain some of this information directly from you, some from the health professional who referred you and some from the home clinic or other healthcare institutions which are involved in your care and treatment.
The Purposes and Legal Bases for which We Process your Personal Information:

  • Where We have a contract to provide HDC, to fulfil this contract, or to take steps linked to the contract such as scheduling treatments or tracking the availability of dialysis stations at holiday dialysis clinics.
  • As required to conduct our business and pursue our legitimate interests, in particular managing complaints or claims.
  • With your consent, for the purpose of providing HDC services:
    • FME will process Medical Data received from you, from the health professional who referred you and from the home clinic or other healthcare institutions which are involved in your care and treatment.
    • FME will transfer your personal information and Medical Data to holiday dialysis units not belonging to FME network and located in countries that have a different data protection regime.

With whom do We share your personal information?
Third parties: To the extent permitted by applicable local provisions, with companies that provide products and services to  FME, such as for invoicing and auditing purpose or for IT support. Other providers or companies that are involved in delivering or funding your care and treatment - including laboratories, transport companies, transplant centers, health insurance companies, dialysis clinics and units either belonging or not to FME network.
Medical Personnel: such as clinical staff for treatment purposes and other medical personnel involved in your holiday dialysis treatment.
FME Personnel: such as Country Medical Directors, members of HDC centers worldwide, and first level support for EuCliD for the purposes of medical treatment and providing recommendations to medical personnel.
Acknowledgement and

Coordination of Holiday Dialysis Treatments - General Terms and Conditions

General Terms and Conditions

§ 1 Preamble
Fresenius Medical Care Italia S.p.A. (in the following “FMC”) operates the coordination centre based in Italy and is responsible for the supporting coordination of dialysis treatments at holiday destinations (in the following “Holiday Dialysis”) of a patient (“Patient”). The Patient wishes to receive dialysis treatments at one or more holiday destinations and asks FMC to coordinate such Holiday Dialysis for him.
Therefore, the Patient and FMC (both hereinafter also referred to as “Party” and together as “Parties“) enter into the following Agreement (in the following „Agreement“).

§ 2 Services of FMC

  1. FMC shall support the coordination of one or more dialysis treatments for the Patient at a center specialized in dialysis treatments identified by FMC in accordance with the criteria indicated by the Patient.
  2. The coordination of Holiday Dialysis includes the evaluation of availability of potential dialysis centers at the requested holiday destination in accordance with the criteria indicated by the Patient in terms of location, period of time and times and frequency of dialysis treatments („Availability Check“). That means, FMC coordinates the availability check request of the Patient in the name of the Patient at an available dialysis center selected by the Patient (in the following “Selected Dialysis Center”) and establishes contact between the Patient and the Selected Dialysis Center.
  3. For the sake of clarification, FMC only provides support to establish the initial contact between the Patient and the Selected Dialysis Center. The final decision and confirmation whether a treatment can be performed during the requested time by Patient is solely at the discretion of the Selected Dialyses Center. In the event of any unforeseen changes (e.g. the first Selected Dialyses Center by the Patient cannot perform the treatment for medical reasons), FMC will support the Patient by trying to establish a further contact with another potential Selected Dialyses Center. However, FMC does not guarantee any positive outcome regarding the realization of the request of the Patient in any way.
  4. The actual treatments are exclusively handled by the Selected Dialysis Center which is fully and exclusively responsible for the treatment. FMC is neither involved in the actual performance and legal compliance of such dialysis treatments nor in the booking or performance of the holiday trip.
  5. If and to the extent, according to the assessment of FMC, assistance or takeover of another coordination centre within the Fresenius Medical Care group of companies (in the following “Alternative Coordination Centre”) is required or helpful in context with organising a Holiday Dialysis in a successful and efficient way, FMC is entitled to involve such alternative coordination center. A list of coordination centers worldwide can be accessed here (https://www.nephrocare.com/patients-home/holiday-dialysis/booking-request.html). The Alternative Coordination Centers provide the same services as provided by FMC under this agreement as subcontractors of FMC.
  6. FMC will provide the above mentioned Services under this Agreement free of charge.

§ 3 Responsibilities of the Patient

  1. The Patient shall provide all personal information required to successfully coordinate the requested Holiday Dialysis. In particular, the Patient shall provide information on his intended holiday trip (destination and period of time) and the requested dialysis times and frequency.
  2. Furthermore, the Patient shall ensure and hereby provides authorization that the physician treating him at his home dialysis center (in the following “home physician”) will provide the Selected Dialysis Center with the required medical and health information as listed in the attached “Holiday Dialysis Request” as soon as possible before the date of the scheduled beginning of the Holiday Dialysis. FMC may assist the Patient by asking the home physician to complete the “Holiday Dialysis Request” and transferring the completed form to the Selected Dialysis Center or by asking the physician at the Selected Dialysis Center to access the data required via the electronic therapy information system “EuCliD 5”.
  3. The Patient shall return signed copies of this Agreement and the attached Consent Form as soon as possible before the date of the scheduled beginning of the Holiday Dialysis that is a prerequisite for FMC to duly start coordinating the requested Holiday Dialysis.
  4. The Parties agree that a holiday dialysis center may deny treatment of a particular Patient at any time during the process supported by FMC according to this Agreement, in particular, if a holiday dialysis center cannot provide the relevant resources required for a particular treatment.

§ 4 Term and Termination
This Agreement takes effect upon being duly signed by the Patient. This Agreement may be terminated by each Party at any time in written form.

§ 5 Liability
FMC is only fully liable for damage caused to the Patient by an intentional or grossly negligent breach of duty by its employees, statutory representatives or auxiliary persons employed to perform duties under this Agreement. Where a claim for damages against FMC is based on simple negligence on the part of FMC (including the persons listed above), FMC is liable only for
death, personal injury or damage to health or,
where the duty breached is an essential contractual obligation on compliance with which the Patient is usually and legitimately entitled to rely as a precondition for due performance of this Agreement, foreseeable damage typical of such contracts.

§ 6 Data Protection
The Patient notices that for the purpose of this Agreement it is necessary to provide and disclose personal data to FMC and  the physicians at the Selected Dialysis Center. The details of data processing operations in context with the coordination of Holiday Dialysis treatments are described in the attached Consent Form that is to be signed by the Patient.

§ 7 Miscellaneous

  1. This Agreement and the contractual relationship is governed by the laws of Italy. The statutory provisions to limit the choice of law and to apply mandatory provisions particularly of the state in which the Patient as a consumer has his habitual residence remain unaffected.
  2. Headlines in this Agreement are not relevant for the interpretation of the Agreement. Should provisions of this Agreement be or become invalid or unfeasible, the validity of the remaining provisions of this Agreement shall not be affected thereby. The parties are required to jointly replace the invalid or unfeasible provision with a valid provision approximating the invalid or unfeasible one as closely as possible. The same applies for any lacunae in this Agreement.
  3. There exist no ancillary verbal side-agreements to this Agreement. Any amendments of this Agreement must be in writing and must be signed by both parties. This does also apply to a change of this written form requirement. Unless legally required elsewhere, e-mail messages are not deemed to satisfy the written-form requirement.