Lymphedema application form

Lymphedema Inquiry form

For Skåne Care to handle your inquiry efficiently and be able to offer the medical treatment you are requesting, please fill in the application form and send together with required documents.
1. MEDICAL CARE REQUEST

Please fill in the application form on following pages.

2. AVAILABILITY AND ESTIMATED COST

Once documents have been received, Skåne Care will verify availability and cost of medical care with the concerned clinic. We will respond to your inquiry within one or two weeks. If you can be offered treatment, we will present a brief treatment plan and an indicative cost for confirmation by you and/or your sponsor. Please note that the cost of treatment is individually set depending on the required intervention.

3. CONFIRMATION AND PAYMENT

Once we receive a confirmation from you and/or your sponsor, we will confirm that the appointment with the medical provider and other requested services for your stay in Sweden are booked. You will need to ensure full financial coverage of the planned care and stay in advance through payment of a bill sent to your address or by submitting a payment guarantee from your sponsor.

4. LOGISTICS AND VISA

The treatment plan and a supporting medical report will be sent to you in advance. If you need to apply for a visa, the medical report should be attached to your visa application which should be submitted at the earliest possible date. For more detailed information about visa applications, contact the Swedish Migration Agency.

Medical Care Inquiry

For Skåne Care to handle your inquiry efficiently and be able to offer the medical treatment you are requesting, please fill in the application form and send together with required documents.
Full Name*

First nameFamily name
Date of birth*

ÅrMånadDag
Sex:*

MaleFemaleOther
Citizenship*
Address*

Street Address 1

Street Address 2

CityState

Zip-codeCountry
Phone Number*

Country codePhone Number
Email*
example@example.com
Spoken Languages*
Interpreter required:*

YesNo

Additional information relevant for medical care and stay in Sweden
How will you finance your medical care in Sweden?*

Private paymentMedical insurancePayment guaranteeOther
Any additional information
Copy of passport*

Cancelof
Medical report in English + photos of your lymphedema arm/leg*

Cancelof

CONSENT FOR PROCESSING OF PERSONAL AND MEDICAL INFORMATION
BACKGROUND

Skåne Care AB will mediate contact with healthcare givers in southern Sweden to provide you with the requested medical care. Skåne Care is subject to rules regarding documentation and handling of patient data according to European legislation GDPR:2018, inter alia General Data Protection Regulation (2018).

CONSENT
1. In order to be able to coordinate and charge for the medical care that you have requested, Skåne Care AB needs your consent to process personal information about you. The data will be processed by employees within Skåne Care AB and by the caregivers involved in your planned medical care. Personal information required to book hotels or other services related to your medical care within the agreement may be disclosed to external recipients to facilitate your medical care and your relatives’ stay. The information that Skåne Care intend to collect and process, is name, date of birth, address and data concerning your medical condition and planned treatments. This information will be saved throughout the application/planning process and for a longer period after provision of care to ensure medical follow up, and as required by Swedish accounting legislation. Rejected applications will be automatically deleted once per calendar year unless a cancellation is made beforehand.

According to GDPR:2018, you have the right to, free of charge and once per year get information about what personal data Skåne Care AB holds about you, including where the data has been collected, the purpose of the processing and to which recipient/recipients the data is disclosed. Application for information shall be made in writing and sent to Skåne Care AB, Trollebergsvägen 5, 222 29 Lund, Sweden
2. Do you agree to Skåne Care AB disclosing information about your medical treatment to your relatives?*

YesNo
I hereby give my consent to the processing of my personal and medical data by Skåne Care AB in accordance with items 1 and 2 above

Clear
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Lymphedema Inquiry form

Medical Care Inquiry

Medical history

And now, please answer some specific questions regarding your lymphedema

Additional information relevant for medical care and stay in Sweden

CONSENT FOR PROCESSING OF PERSONAL AND MEDICAL INFORMATION