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 implementation of the Law on patient rights no. 46/2003, ensuring compliance with the following rules:

1) Requests regarding the communication of personal medical data are addressed by patients / relatives / authorized persons, in writing, by completing the form "Request for 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 forwarded to the Medical Evaluation and Statistics Service for resolution.

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

3) In the case of authorized persons requesting patients' medical documents, 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 copies of requested medical documents is carried out by the person nominated 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) The issuance of copies of 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.

The regulation of the process of issuing medical documents requested by patients / relatives / authorized persons or other persons entitled to access information, according to the law, has as 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 the doctors nominated by the patient in Annex no.5 to the rules "Patient’s consent regarding the communication of personal medical data" (Law 46/2003 as updated).

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

c) If the patient was unable to express consent and death has 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:

- the surviving spouse;

- descendants;

- ascendants/guardians;

- 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) unconscious state.

3) physical incapacity that makes it impossible to express consent.

The persons referred to in letter c) shall submit to the management of the health 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.