Requesting a copy of medical records

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Requesting a copy of medical records

With this form you can request a copy of medical recors.

Surname / maiden name of patient: *

Initial(s) *

Date of birth: *

CSN: *

Street and house number: *

Postal code and place of residence: *

Telephone/mobile: *

E-mail: *

If you, as the applicant, are not the patient. The patient must give consent for the request of medical data.

If you, as the applicant, are not the patient it is mandatory the patient signs the form manually. You can print this form, fill it in and let the patient sign this. The signed form you can submit via e-mail ([email protected]) or sent by post.

Which specialism(s) do you want to receive data from? *

Can you give the period of this data? *

Please indicate whether you want to receive a CD-ROM of X-ray / MRI scan / CT scan

Please indicate below which information you want to receive from the medical records. Choose from: Dismissal letter to general practitioner, operation report, nursing file, something else, such as... *

What is the reason for the request? *

Second opinion

Other institution / hospital

Personal injury / legally

Privately

The patient / applicant declares to have been informed of the conditions (e.g. costs) that apply to the request of the medical records as stated in the brochure or on the website. *

I have been informed of the conditions

NOTE: Handling your application will take some time. Keep this in mind when making an appointment for a second opinion, for example. You will receive a message by e-mail when the requested information is ready.

Add a copy of your valid ID (ID, passport or driver's license) *

If you are not the patient, add a copy of the valid ID of the patient

If necessary, add a separate attachment with your motivation for your request for a deceased patient