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 Rules for the Application of the Patient Rights Law no. 46/2003, following the observance of the following rules:

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

3) 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.

4) The issuance of copies of the requested medical documents is done 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 representatives complete 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 representatives or other persons entitled to access information, according to the law, has as main objectives:

a) The patient has unrestricted access to personal medical data, under the terms of the law. The patient's access to medical data can be direct or indirect – through legal relatives or through doctors designated by the patient in Annex no.5 to the norms “The 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, and personal data are confidential, even after the patient's death. This information may only be provided 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 the patient's treatment, provision of consent is no longer mandatory. (Law 46/2003 updated).

c) In situations where the patient was unable to express consent and death intervened, 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) 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 expressing consent impossible.

The persons provided 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.