Before you complete this form, we would like to point out that a large part of the patient's medical file can be viewed in our My UMC Utrecht patient portal. This information is directly available to the patient and always up to date. The following data can be consulted in My UMC Utrecht:
- Personal data (including contact persons and consents given)
- General data (including allergies, implants and treatment restrictions)
- Letters, consultations, reports and questionnaires
- Medications (current and history)
- Appointments, admissions, operations, examinations and measurements
- Radiology and surgery reports
- Laboratory results (including blood, bacteriology/virology, pathology and endoscopy)
In order for us to process your request, we would like to ask the following from you:
- You complete the form below in full;
- You take a scan of your passport/ID card and a scan of the patient's passport/ID and attach both to this form;
- You attach a completed authorisation form to this form (in Dutch).
Good to know:
- There is no charge for a one-off request for a copy of medical records.
- If you request the file of a deceased or incapacitated patient, you do not need to add the patient's signature or proof of identity to the form.
- Receiving the file of a deceased patient is not always possible. A healthcare provider's professional confidentiality applies even after death. In order to provide a copy, there must be a legal basis for breaking professional secrecy. Read more information about this on the website of the Patients Federation (in Dutch).
- Your requested records will be sent to you by secure e-mail. If you prefer to receive the file by another method, please indicate this at the bottom of the form.
Have you filled in the form fully and truthfully and added a copy of your ID and signature? Then click on “send”. You will receive a confirmation from us via email once we have received your application.
