Application for a copy of medical records (applicant is not the patient)

When the applicant is not the patient who’s medical records are requested, please fill out this form.

Details applicant:

Patient details

The applicant requests the following records:

(tick the box,  subject, location and period are mandatory)

N.B. Generally you receive the specialist’s letter which was sent to
the general practitioner, in which an overview is included of the specialists findings during the treatment.

Your request will be dealt with within four weeks. If you do have any questions, please contact the departments medical secretary of the department in question.

When inspecting or collecting the medical records from the hospital, the applicant needs to bring:

  • Authorization to release medical records, download en print the form here
  • His or her means of identification*
  • A copy of the means of identification of the patient*

* Valid means of identification:

  • Passport
  • Identification card
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