Medical Records Request Form Template for Netherlands

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Key Requirements PROMPT example:

Medical Records Request Form

"I need a Medical Records Request Form for a Dutch general practice that allows patients to request their complete medical history, with specific provisions for electronic delivery and clear GDPR compliance statements."

Document background

The Medical Records Request Form is a crucial document used in the Dutch healthcare system to facilitate the legal and secure transfer of medical information. It is designed to comply with the Dutch Medical Treatment Contracts Act (WGBO), the General Data Protection Regulation (GDPR), and other relevant Dutch healthcare legislation. This form is essential when patients or authorized parties need to access medical records from healthcare providers, ensuring proper documentation of consent and specific request details. It serves multiple purposes, including transferring care between providers, obtaining second opinions, legal proceedings, or personal record keeping. The document includes necessary safeguards for patient privacy while providing healthcare providers with clear authorization for release of medical information.

Suggested Sections

1. Patient Information: Personal details of the patient including full name, date of birth, BSN number, address, and contact information

2. Requesting Party Information: Details of the person requesting the records (if different from patient), including relationship to patient and contact information

3. Healthcare Provider Information: Details of the healthcare provider or institution from whom records are being requested

4. Records Request Specifications: Detailed description of which medical records are being requested, including date ranges and types of records

5. Purpose of Request: Clear statement of why the medical records are being requested, as required by GDPR

6. Patient Rights Statement: Statement of patient rights regarding their medical records under WGBO and GDPR

7. Consent Declaration: Explicit consent statement for the release of medical records, including data processing consent under GDPR

8. Verification and Authentication: Requirements for identity verification and authentication of the request

Optional Sections

1. Third Party Authorization: To be included when records are requested by someone other than the patient, including legal representative authorization details

2. Urgent Request Details: To be included when expedited processing is required, including justification for urgency

3. Special Categories of Data: Additional consent sections for sensitive medical information like psychiatric records or genetic data

4. International Transfer Details: Required when medical records need to be transferred outside the Netherlands/EU, addressing GDPR requirements for international data transfer

Suggested Schedules

1. Identity Verification Documents: List of acceptable identity verification documents and copies to be attached

2. Authorization Form: Standard form for third-party authorization if applicable

3. Fee Schedule: Overview of any applicable fees for processing the request and providing copies

4. Record Types Checklist: Detailed checklist of different types of medical records that can be requested

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

General Practice

Specialist Medical Care

Mental Healthcare

Legal Services

Insurance

Healthcare Technology

Public Health

Relevant Teams

Medical Administration

Patient Services

Legal Affairs

Compliance

Data Protection

Healthcare Information Management

Quality Assurance

Medical Records

Privacy Office

Patient Relations

Relevant Roles

Medical Records Officer

Healthcare Administrator

Data Protection Officer

Privacy Officer

Medical Secretary

Healthcare Provider

General Practitioner

Medical Specialist

Legal Counsel

Compliance Officer

Patient Services Coordinator

Healthcare Quality Manager

Practice Manager

Hospital Administrator

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Authors

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