Authorization to release medical records

When the applicant is not the patient who’s medical records are requested, please fill out the authorization to release medical records.

Download en print the form here .

Do not forget to attach a copy of your means of identification*. The person you are authorizing also needs to provide his or her means of identification when inspecting or collecting your medical records from the hospital.

* Valid means of identification:

  • Passport
  • Identification card

 

Om franciscus.nl goed te laten functioneren maken we gebruik van cookies. Bekijk ons cookiebeleid