Comisión Estatal de Conciliación

y Arbitraje Médico para el Estado de Colima

Formato Único de Inconformidad Médica

FECHA: ______/______/__________

DATOS DEL USUARIO

Nombre:  ______________________________________________________________________________________________________________ Sexo:  _____________________________________________      Edad: _________________________________

Domicilio:  ___________________________________________________________________________________________________________________________________________________________________ Entidad Federativa: ___________________      

Teléfono: _______________________________________________________________________________________________________  CURP__________________________________________________________________________________________       

Institución: ____________________________________________________________  Afiliación: ____________________________  Identificación: _______________________________________________________________________________________ 

DATOS DEL PROMOVENTE

Nombre:   _____________________________________________________________________   Domicilio:  _________________________________________________________________ Entidad Federativa: ______________________________________      

Teléfono: _______________________________________________________________________________________________________________________________________________________________________________________________________       

Causa de Representación: __________________________________________________________________________________________________________________________________________________________________________________________     

___________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________

PRESTADOR(ES) DEL(LOS) SERVICIO(S)

Nombre:  _____________________________________________________________________________________________________________________________________________________________________________________________________       

Domicilio:  _______________________________________________________________________________________________________________________________________________________________________________________  

Teléfono:    _________________________________________________________________________________________________________________________________________________________________________________________________    

 Hechos: ________________________________________________________________________________________________________________________________________________________________________________________

 ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 DE MANERA EXPRESA MANIFIESTO QUE LA INFORMACIÓN PROPORCIONADA PARA EFECTOS DE DESAHOGAR MI INCONFORMIDAD, DEBE TENERSE COMO CONFIDENCIAL.

__________________________________

NOMBRE Y FIRMA