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

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

a) The request regarding the communication of personal medical data is addressed by patients / relatives / authorized representatives, in writing, by completing the form "Request regarding the communication of personal medical documents," provided in Annex no. 3 to OMS 1410/2016. The respective form is approved by the hospital commander and is assigned to the designated structure for resolution.

b) In the case of minors, adults without discernment, and adults with temporary loss of exercise capacity, the applicant must prove that he/she is a relative / legal representative.

c) In the case of authorized persons requesting medical documents of the patients, it is necessary to attach the "Patient's Agreement regarding the communication of medical data" provided in Annex no. 5 to OMS 1410/2016.

d) The issuance of copies of requested medical documents is carried out by the person nominated by the designated structure together with the archivist, within 30 calendar days from the registration at the institution's headquarters.

e) The issuance of copies of the requested medical documents is performed after the patients / relatives / authorized representatives complete the form "Declaration regarding the communication of personal medical documents," provided in Annex no. 4 to OMS 1410/2016.

The regulation of the process for issuing medical documents requested by patients / relatives / authorized representatives 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 conditions of the law. The patient's access to medical data can be direct or indirect – through legal relatives or through doctors nominated by the patient in Annex no.5 to the norms "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 the patient's death. This information can only be provided 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, consent is no longer mandatory. (Law 46/2003 updated).