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 Norms of the Patient Rights Law no. 46/2003, following the observance of the following rules:

1) The request regarding the communication of personal medical data is addressed by patients / relatives / authorized persons, in writing, by completing 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 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 that they are a relative / legal representative.

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

4) The release 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 release of copies of the requested medical documents takes place after patients / relatives / authorized persons complete the form "Declaration regarding the communication of personal medical documents," provided in Annex no. 4 to OMS 1410/2016, with subsequent amendments and additions, at the institution's headquarters.

The regulation of 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 the following 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 may be direct or indirect – through legal relatives or through doctors nominated by the patient in Annex no. 5 to the norms "Patient's consent 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 necessary for other accredited medical service providers involved in treating 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 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/guardians;

- collateral relatives up to the fourth degree inclusive.

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 that makes consent expression impossible.

The persons mentioned in letter c) will submit to the management of the medical 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 additions.