The clinic does not provide a referral or the patient’s medical documents – what to do?

In Ukraine, every patient has a guaranteed right to receive medical services and access to their own medical information. However, in practice, sometimes situations arise when a doctor refuses to issue an electronic referral or does not provide medical information.

What is an e-referral and when is it needed?

An e-referral is an electronic document that a doctor issues for a patient to access certain medical services paid for by the state within the framework of the Medical Guarantees Program.

Usually, a referral is required for consultations with narrow-profile specialists (cardiologist, endocrinologist, etc.). However, there are exceptions - without a referral, you can contact a gynecologist, psychiatrist, narcologist, dentist (urgent care) and some other specialists.

The patient's right to medical documentation

According to the Fundamentals of Ukrainian Legislation on Healthcare, the patient has the right to:

1. receive complete information about his or her health;
2. get acquainted with medical documentation related to his or her treatment;
3. receive copies of medical documents upon request.

The healthcare institution is obliged to provide such documents, except in cases where their disclosure may cause harm to the patient or other persons. In such cases, the refusal must be duly justified.

However, it should be noted that the patients' medical records - inpatient (form No. 003/o) and outpatient (form No. 025/o) - are the property of the healthcare institution. The only document that a patient can officially receive is an extract from the medical record (form No. 027/o).

In practice, many hospitals have an internal ban on photography or videography. Therefore, the patient may be refused permission to photograph the card. However, he has the right to officially contact the medical institution with a written request and receive an extract or copy of his medical records.

What to do if the clinic refuses to issue a referral or medical records?

• Contact the institution's management. Demand an official explanation of the reasons for the refusal.
• Call the National Health Service of Ukraine contact center or the Ministry of Health hotline. Specialists will provide clarification and suggest an algorithm for further actions.
• File a complaint. In the event of an unjustified refusal, you have the right to file a complaint against the actions of the doctor or medical institution.
• If necessary, go to court.

Is it possible to request medical documents through a lawyer's request?

It is worth noting that a lawyer can request medical documents through a lawyer's request, but there are certain conditions. The request must be justified, related to the provision of legal assistance to the client and meet the requirements of the law. He must also have the appropriate powers, confirmed by a warrant / agreement on the provision of legal assistance.

The advantages of using this service include:

1. Legal obligation to perform. Responding to a lawyer's request is an obligation for a medical institution in accordance with the Law of Ukraine "On Advocacy and Advocacy", and ignoring such a request entails administrative liability.
2. Speed ​​of obtaining information. The medical institution is obliged to provide a response within 5 business days.
   Guarantee of completeness / reliability of data. The institution is obliged to provide documents in full and without distortions.
3. Protection of patient rights. With the help of a lawyer's request, you can get a medical history, test results, discharge notes and other medical documents that the patient is refused to give directly. This is especially important in cases of litigation (for example, about improper medical care).
4. Psychological factor. Clinics usually take lawyer's requests more seriously than personal statements from patients.

How can we help?

If you are faced with a medical institution refusing to provide a referral or medical documents, we recommend that you first contact a medical lawyer for advice. Our specialists in the field of medical law will help you:

1. provide individual legal advice and determine the most effective way to resolve the problem;
2. request the necessary medical documents using a lawyer's request;
3. prepare and submit complaints to regulatory authorities;
4. provide full support for a medical dispute, including representation in court;
5. protect your rights in disputes with medical institutions.

Do you have any questions? Leave a request on our website and our lawyer will contact you to clarify the circumstances of the case.