The procedure aims to regulate the specific conditions for the issuance of medical documents requested by patients / relatives / authorized persons as well as the conditions for transmitting the patient's medical data.

The issuance of medical documents requested by patients / relatives / authorized persons is carried out in strict accordance with the provisions of OMS 1410/2016 regarding the approval of the Application Rules of the Patient Rights Law no. 46/2003, following compliance with the following rules:

1) The request for communication of personal medical data is submitted in writing by patients / relatives / authorized persons by completing the "Request regarding the communication of personal medical documents" form, provided in annex no. 3 to OMS 1410/2016. This form is approved by the hospital commander and is assigned to the Medical Evaluation and Statistics Service for resolution.

2) In the case of minors, adults without discernment, and adults with temporary loss of exercise capacity, the applicant must prove the status of relative / legal representative.

3) For authorized persons requesting medical documents of patients, it is necessary to attach the “Patient's consent for communication of medical data” provided in annex no. 5 to OMS 1410/2016.

4) Issuance of copies of the requested medical documents is carried out by the person designated by the head of the Medical Evaluation and Statistics Service together with the archival fund manager, within 48 hours from registration at the institution's headquarters.

5) Issuance of copies of the requested medical documents takes place after the patients / relatives / authorized persons fill in the “Declaration regarding the communication of personal medical documents” form, provided in annex no. 4 to OMS 1410/2016, with subsequent amendments and completions, at the institution's headquarters.

Regulation of the process of issuing medical documents requested by patients / relatives / authorized persons or other persons entitled to access to information, according to the law, has the following main purposes:

a) The patient has unrestricted access to personal medical data, under the law. The patient's access to medical data can be direct or indirect – through legal relatives or through doctors designated by the patient in Annex no.5 to the rules “Patient's consent for communication of personal medical data” (Law 46/2003 updated).

b) All information regarding the patient's condition, the results of investigations, diagnosis, treatment, personal data are confidential, even after their death. This information can be provided only if the patient gives explicit consent or if the law expressly requires it. If the information is needed by other accredited medical service providers involved in the treatment of the patient, granting consent is no longer mandatory. (Law 46/2003 updated).

c) In the situation where the patient was unable to express consent and death has occurred, confidential data from the observation sheet, information about the patient’s condition, the results of investigations, diagnosis, prognosis, treatment, personal data, may be provided, upon request, to the following persons, in the order below:

- the surviving spouse;

- descendants;

- ascendants/guardians;

- relatives in the collateral line up to the fourth degree inclusive.

d) Situations in which the patient is unable to express consent are the following:

1) coma state.

2) state of unconsciousness.

3) physical incapacity making consent impossible to express.

The persons provided in letter c) will submit to the management of the healthcare unit a declaration on their own responsibility, the model of which is provided in annex no. 6 to OMS 1410/2016, with subsequent amendments and completions.