Requesting a copy of medical records

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

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 (mere@zha.nl) or sent by post.

 

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.