REPORT A DISCRIMINATION CASE MSR

Health mediator details

Fill in the professional and contact details needed for any follow-up clarifications.

Full name

County / Locality

Institution where you work

Phone

Email address

Description of the situation

Select the report type and present the context of the case, the institution involved, and the essential elements that explain how the reported situation occurred.

Report type

Date / period

Medical unit involved

Detailed description of the situation

Identified impact

Mark the observed consequences and explain the effects on the beneficiary, the community, or your professional activity.

Evidence and documentation

Note what types of evidence or supporting materials already exist and may support the internal review of the case.

Supporting documents exist

Witnesses exist

Written correspondence exists

Other evidence

Previous steps

Mention the institutions already contacted and the current stage of discussions or the responses received so far.

Medical unit management

Public Health Authority

Town hall

Another institution

Result

Type of support requested

Choose the form of support you consider useful for continuing the case or protecting your professional activity.

Legal review of the case

Support for an NCCD complaint

Support for institutional intervention

Assessment for strategic litigation

Professional protection (in case of pressure)

Declaration and data protection

Confirm that the information is true and your explicit consent for processing the data, including any special categories of data you choose to include, for the purpose of reviewing the report.

I declare that the information provided is true to the best of my knowledge.

I give my explicit consent to the processing of my personal data and, where applicable, the special categories of data I choose to include in this report, including health data or information that may reveal ethnic origin, for the purpose of reviewing the report, in accordance with Regulation (EU) 2016/679 (GDPR).

Before you send

This channel is intended to document cases and practices that may involve sensitive data about beneficiaries, mediators, or other persons interacting with the healthcare system.

Required fields are necessary to register and review the report and to handle any follow-up clarifications.
Include only the data that is strictly necessary and avoid excessive detail about third parties. If you report on behalf of a beneficiary, make sure you have a legitimate basis to share the data.
Resolved reports may be archived after at least 180 days of inactivity and scheduled for deletion 365 days after archival, unless the law or the defence of legal claims requires longer retention.
You may withdraw consent at any time, without affecting the lawfulness of processing carried out before withdrawal. Withdrawal may nevertheless limit our ability to continue reviewing the report.

See: GDPR policy · Protection policy · Terms and conditions

Health mediator details

Fill in the professional and contact details needed for any follow-up clarifications.

Full name

County / Locality

Institution where you work

Phone

Email address

Description of the situation

Select the report type and present the context of the case, the institution involved, and the essential elements that explain how the reported situation occurred.

Report type

Date / period

Medical unit involved

Detailed description of the situation

Identified impact

Mark the observed consequences and explain the effects on the beneficiary, the community, or your professional activity.

Evidence and documentation

Note what types of evidence or supporting materials already exist and may support the internal review of the case.

Supporting documents exist

Witnesses exist

Written correspondence exists

Other evidence

Previous steps

Mention the institutions already contacted and the current stage of discussions or the responses received so far.

Medical unit management

Public Health Authority

Town hall

Another institution

Result

Type of support requested

Choose the form of support you consider useful for continuing the case or protecting your professional activity.

Legal review of the case

Support for an NCCD complaint

Support for institutional intervention

Assessment for strategic litigation

Professional protection (in case of pressure)

Declaration and data protection

Confirm that the information is true and your explicit consent for processing the data, including any special categories of data you choose to include, for the purpose of reviewing the report.

I declare that the information provided is true to the best of my knowledge.

Before you send

This channel is intended to document cases and practices that may involve sensitive data about beneficiaries, mediators, or other persons interacting with the healthcare system.

Required fields are necessary to register and review the report and to handle any follow-up clarifications.
Include only the data that is strictly necessary and avoid excessive detail about third parties. If you report on behalf of a beneficiary, make sure you have a legitimate basis to share the data.
Resolved reports may be archived after at least 180 days of inactivity and scheduled for deletion 365 days after archival, unless the law or the defence of legal claims requires longer retention.
You may withdraw consent at any time, without affecting the lawfulness of processing carried out before withdrawal. Withdrawal may nevertheless limit our ability to continue reviewing the report.

See: GDPR policy · Protection policy · Terms and conditions