Copy of medical records
If you want to request a copy of a part or all of the medical file, you can download the application form, print it, fill it out and sign it. Click here for the application form. You can also fill in the online form for requesting a copy of medical records
If the application form is completed by someone other than the patient, the patient must also sign this form. In this way, the patient gives permission to the applicant to request his /her file. This does not apply if:
- parents or legal representatives request the medical records of their child younger than 12 years of age;
- if a patient himself is not able to give permission (the patient is incompetent or deceased). A signature of the applicant is then sufficient. The physician or attending physician will thereby have to weigh the interests between the possibly substantial interest of the legal representatives / survivor (s) at issue and the importance of protecting the privacy of the patient or deceased patient. The doctor who has been involved in the treatment or the medical department head decides whether the explanation is sufficient to breach the right of privacy for an incompetent patient or after the death of the patient. The doctor may also consider requesting written permission with signatures from each legal family member of the same bloodline.
Add a valid proof of identity!
The patient is asked to include a copy of a valid identity document (identity card, passport or driving license). If the file is requested by someone other than the patient, then we also ask that person to include a copy of a valid ID. Therefore it may happen that you need to include two copies.
For patients younger than 12 years of age or who are incapable of giving consent themselves, a copy of the identification document is not necessary.
Where do I submit the form?
You can submit the form with a copy of your valid identification document to the following department:
Attn: Secretariat of the Board of Directors
1180 AH AMSTELVEEN
If you have questions about your medical file, you can contact, the secretariat of the Board of Directors on Monday, Tuesdayday and Thursday and Friday between 9.00 am and 10.00 am, via +31 (0) 20 - 755 6300, or email@example.com
When the copy of your file is ready, you will be notified by e-mail. You can then pick up the copy of the file at the registration desk. Your request will be added to your medical record. Please note that it may take around 3 weeks before you have the copy of your file in your possession. Your (attending) physician is to provide permission for the provision of the data.