The purpose of the procedure is to regulate the specific conditions for issuing 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, aiming to comply with the following rules:

1) The request regarding the communication of personal medical data is made by patients / relatives / authorized persons, in writing, 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 exercising capacity, the requester must prove that they are a relative / legal representative.

3) In the case of authorized persons who request medical documents of patients, it is necessary to attach the "Patient's consent regarding the communication of medical data" provided in annex no. 5 to OMS 1410/2016.

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

5) The issuance of copies of the requested medical documents takes place after patients / relatives / authorized persons fill out 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.

The regulation of the process for issuing medical documents requested by patients/ relatives/ authorized persons or other individuals entitled to access information as per the law has the following main purposes:

a) The patient has unrestricted access to personal medical data, according to the law. The patient's access to medical data can be direct or indirect – through legal relatives or through doctors nominated by them in Annex no.5 to the rules "Patient's consent regarding the communication of personal medical data" (Updated Law 46/2003).

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

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

- surviving spouse;

- descendants;

- ascendants/tutors;

- collateral relatives up to the fourth degree inclusive.

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

1) comatose state.

2) state of unconsciousness.

3) physical incapacity making consent impossible to express.

The persons provided for in letter c) will submit to the management of the sanitary 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.