The procedure aims 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 Rules for the application of the Patient's Rights Law no. 46/2003, ensuring compliance with the following rules:

1) The request for the communication of personal medical data is addressed by patients / relatives / authorized persons, in writing, by filling out the form "Request regarding the communication of personal medical documents", 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 applicant must prove that they are a relative / legal representative.

3) In the case of authorized persons requesting medical documents of patients, they are required 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 the requested copies of medical documents is performed by the person designated 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 the patients / relatives / authorized persons fill in the form "Declaration regarding the communication of personal medical documents", provided in Annex no. 4 to OMS 1410/2016, with subsequent amendments and completions, at the institution's headquarters.

Regulating the process of issuing medical documents requested by patients/ relatives/ authorized persons or other persons entitled to have access to information, according to the law, has as its 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 nominated by them in Annex no.5 to the rules "Patient's agreement regarding the communication of personal medical data" (Law 46/2003 updated).

b) All information regarding the patient's condition, investigation results, diagnosis, treatment, personal data is 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 treating the patient, providing consent is no longer mandatory. (Law 46/2003 updated).

c) In the situation where the patient was unable to express consent and their death has occurred, confidential data from the observation sheet, information about 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/guardians;

- collateral relatives up to and including the fourth degree.

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

1) comatose state.

2) state of unconsciousness.

3) physical incapacity making it impossible to express consent.

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.