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

The issuance of medical documents requested by patients / family members / 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 Rights Law no. 46/2003, following the observance of the following rules:

1) Requests regarding the communication of personal medical data are addressed by patients / family members / authorized persons, in writing, by filling in 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 commander of the hospital and is distributed to the Medical Evaluation and Statistics Service for resolution.

2) In the case of minors, adults lacking discernment, and adults with temporary loss of capacity, the applicant must prove that they are a family member / legal representative.

3) In the case of authorized persons requesting 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 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 the registration at the institution's headquarters.

5) The release of copies of the requested medical documents takes place after the patients / family members / 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.

The regulation of the process of releasing medical documents requested by patients / family members / 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 may be direct or indirect—through legal family members or through doctors designated by them in Annex no. 5 to the rules "Patient's consent regarding the communication of personal medical data" (Law 46/2003 updated).

b) All information regarding the patient's state, investigation results, diagnosis, treatment, personal data is confidential, even after their 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 medical service providers involved in treating the patient, obtaining consent is no longer mandatory. (Law 46/2003 updated).

c) In the situation where the patient was unable to express consent and death has occurred, confidential data from the observation sheet, information regarding the patient's status, the results of investigations, 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) 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 provided for in point 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 completions.