Request form for copy of data from your medical record

YOUR PERSONAL DETAILS

Last name (as stated in passport or ID):

First name:

Initials:

Date of birth:

Address:

Postal code:

Place of residence:

Telephone number:

Email address:

Patient number UMC Utrecht:

Gender: Male Female Other

YOUR APPLICATION

I would like to request data on the following specialism(s):

I would like to receive data from my medical records for the period from / to (e.g. 1 January 2021 to 31 January 2021).

If you would like to receive the data via secure email, please enter the email address to which you would like the data sent below.

If you would like us to share the data with you via secure email, we will need your mobile phone number. If you do not provide this, we will unfortunately be unable to email you the data securely. Please enter your mobile phone number in the field below.

YOUR MEDICAL RECORDS

Please select one or more of the following items for which you would like to receive a copy General medical information (e.g. allergies, isolation indication) Appointment and admission overview Consultations Correspondence (letters) Medication list (from 2011 onwards) Results (including blood, urine and virology) Results (bacteriology) Pathology reports Radiology reports* Other data**

If you would like to receive other data, please indicate this below:

* In radiology reports, you will find the conclusions of your radiological examinations given by the specialist. If you would also like to receive radiology images, please note which images are concerned under "Other data". We deliver radiology images via secure email as standard.

** The above data contain a considerable part of your medical file. The above data are usually sufficient. If you wish to request more data, please note under "Other data" which parts of your file you wish to receive. If necessary, you can ask your specialist what other data might be important to you.

Reason for request: Second opinion Continuation of treatment elsewhere Complaint/dissatisfaction with treatment Need for additional/supplementary information Interest Other, namely;

If you selected ‘other, namely’, please state the reason for your request here:

If you have any comments regarding this request, please enter them below:

Please attach a scan of your valid driving licence, ID card or passport here. Voeg een bijlage toe max. 5MB

We process your proof of identity for the purpose of the identification process. This is immediately removed by us at the time we have identified you.

Add your signature here. Voeg een bijlage toe max. 5MB

If you are requesting data related to your IVF treatment, please attach a valid identification document and signature of your partner below. If you are using a donor, you do not need to attach anything.

Please attach a scan of your partner's valid driving licence, ID card or passport here. Voeg een bijlage toe max. 5MB

Add the partner's signature here. Voeg een bijlage toe max. 5MB

I would like to receive my file in the following manner: Secure email USB stick On paper

Have you completed the form fully and truthfully and added a copy of your ID and signature? Then click on 'Submit'. You will receive confirmation from us via an e-mail message once we have received your application.