Description of the procedure for providing information on the patient and the services provided to him/her
UAB FORMA PERFECTA
DESCRIPTION OF THE PROCEDURE FOR PROVIDING INFORMATION ON THE PATIENT AND THE SERVICES PROVIDED TO HIM/HER
14 April 2021
1. GENERAL PROVISIONS
1.1. The Description of the Procedure for Providing Information on the Patient and the Services Provided to him/her of UAB Forma Perfecta (hereinafter – the Description) was prepared in accordance with the Law of the Republic of Lithuania on Patients’ Rights and Compensation for Health Damage approved by Order No. 65 “On the Approval of the Procedure for Providing Information on the Patient to State Institutions and Other Authorities” of 1 February 2001, Order No. V-506 “On the Provision of Written Information, including Confidential, on the Patient and the Services Provided to him/her and the Approval of the Description of the Procedure for Payment for this Service” of Minister of Health of the Republic of Lithuania of 20 May 2011 , Order No. V-658 “On the Proper Implementation of the Patient’s Right of Access to Records in Medical Documents” of 1 July 2011 and other legal acts regulating the procedure for providing information about the patient.
1.2. The description regulates UAB Forma Perfecta Information on the patient’s health condition, diagnoses and treatment, as well as the conditions, terms and payment procedure for providing all other information about the patient to the patient, state institutions and other authorities and persons.
2. DEFINITIONS USED IN THE DESCRIPTION
2.1. Identity document – a passport or identity card of a citizen of the Republic of Lithuania, a temporary certificate issued upon loss of an identity card or passport, a permit for temporary (permanent) residence in Lithuania, as well as a passport of a foreign citizen or other travel document corresponding to it or a travel document of a stateless person as defined in the Law of the Republic of Lithuania on the Legal Status of Aliens (No. IX-2206 of 29 April 2004). The document must contain a sample of the person’s signature.
2.2. Representative under assignment – a person who has a power of attorney issued by an adult, legally competent patient, notarised and valid, which gives the right to receive Information about the patient, or a lawyer who has a valid representation agreement with such patient;
2.3. Statutory Representative – a person acting on behalf of a minor patient and/or a patient who cannot be considered able to reasonably assess his/her interests, as defined in Article 6.744 of the Civil Code of the Republic of Lithuania;
2.4. Clinic – UAB Forma Perfecta, legal entity code 304953287, address Sporto g. 3, Kaunas;2.5.
2.5. Information on the patient – patient data (name, surname, date of birth, personal identification number, address, telephone, e-mail address), presence in a health care institution, health condition, diagnosis, medical examination data, course and prognosis of treatment, other information related to the patient’s treatment. All information about the patient, even after his/her death, is confidential;
2.6. Consent – the written (signed by the patient) consent (original) of the patient (representative) regarding the provision of Information on the patient to a third party, which states:
2.6.1. persons to whom confidential information may be provided – Name, Surname/Title and contact details of the person entitled to receive the information (telephone number, e-mail);
2.6.2. the extent of the information provided (e.g. Information on injuries, information for period “X”). In the event that the patient does not specify the scope of the provision of information in the consent, it shall be deemed that, at the request of the person specified in the consent, any Information on the patient available to the Clinic may be provided;
2.6.3. The consent also recommends specifying the basis for providing the information (e.g. insurance contract), the purposes of use (e.g. determining the validity of the insurance benefit) and the period of validity of the consent.
3. GENERAL PROVISIONS FOR THE PROVISION OF INFORMATION
3.1. Information on the patient under the conditions specified in this Description may be provided to the following persons:
3.1.1. the patient;
3.1.2. the patient’s representative;
3.1.3. the person to whom the patient has agreed to disclose information about his or her health;
3.1.4. persons who have the right to receive such information in accordance with the procedure established by legal acts.
3.2. After the patient’s death, the patient’s heirs have the right to receive Information on the patient.
3.3. Requests may be submitted by interested parties:
3.3.1. directly at the Clinic reception at Kaunas, Sporto str. 3;
3.3.2. by sending it to the Clinic by post or by courier to Sporto str. 3, Kaunas;
3.3.3. in the cases and under the procedure specified below in this Description by e-mail firstname.lastname@example.org.
3.4. If the applicant wishes to receive documents by e-mail, the request must clearly state such a request and the e-mail address to which the Information on the patient must be provided, as well as other electronic means of communication (telephone number, etc.) required to prove identity of the applicant.
3.5. In the cases and according to the procedure specified in this description, the Clinic provides Information on the patient to the patient and other persons entitled to receive it free of charge.
4. PROVISION OF INFORMATION TO THE PATIENT
4.1. A patient who presents identity documents has the right to receive Information on his or her state of health, diagnosis of the disease, other treatments or examinations used in the healthcare facility or known to the doctor, potential risks, complications, side effects, treatment prognosis and other circumstances that may have influence the patient’s decision to accept or refuse the proposed treatment, as well as the consequences of refusing the proposed treatment.
4.2. The Clinic shall provide the patient with copies of his/her medical records or any other Information on the patient available to the Clinic specified in the patient’s request, including descriptions of diagnosis and treatment.
4.3. The patient’s request must be submitted in writing, except for a request for copies of the patient’s medical records, which may be made orally at the Clinic’s reception.
4.4. The patient can also submit the request to the Clinic by e-mail info@fiClinica.lt, if he/she has indicated the e-mail address in his/her contact details with signed confirmation and the patient’s request is received from this e-mail address.
4.5. The patient submits an identity document to the Clinic together with the request . If the request is sent by post or courier, the patient provides a copy of the identity document certified by a notary or lawyer.
4.6. The Clinic refuses to provide information to the patient when:
4.6.1. disclosure of Information on the patient would harm the patient’s health or endanger his or her life (the decision is made by the attending physician, indicating the decision and its reasons in the medical records);
4.6.2. The Clinic cannot properly identify the patient when he or she contacted the electronic means of communication.
5. PROVISION OF INFORMATION TO PATIENT REPRESENTATIVES AND Heirs
5.1. Information on the patient may be provided to the patient’s Statutory Representatives and/or Representatives under assignment, and after the Patient’s death – to the patient’s heirs who have the documents confirming the basis of representation;
5.2. At the written request of the representative, all the Information on the patient available to the Clinic shall be provided, but only to the extent that does not exceed his/her powers established in the document establishing the basis of representation.
5.3. In order to obtain Information on the patient, the patient’s Representative shall provide the Clinic with:
5.3.1. a written request stating the nature of the information and the purpose for which it is to be used;
5.3.2. an Identity document. If the request is sent by post or courier, or by e-mail, the patient’s representative shall provide a copy of this document certified by a notary or lawyer;
5.3.3. the original of the document certifying the basis of representation, a copy certified by a notary or a lawyer representing him/her:
5.4. The following shall normally be considered as supporting documents for the Statutory Representative’s representation:
5.4.1. the patient’s birth certificate, which indicates the family relationship between the patient and the Representative;
5.4.2. the decision of the relevant state authority or court (guardians (carers));
5.4.3. marriage certificate (when the Statutory Representative is a spouse);
5.4.4. other documents that may prove the basis of statutory representation;
5.5. In order to obtain Information on the patient after the death of the patient, the heir shall provide the Clinics with the documents specified in clauses 5.3.1-5.3.2
5.5.1. a certificate of succession right issued by a notary or a person equivalent thereto, or another equivalent document;
5.5.2. a certificate of the patient’s death or a document certifying the family relationship of the heir to the patient (heirs by operation of law);
6. PROVISION OF INFORMATION TO A THIRD PARTY WITH THE PATIENT’S CONSENT
6.1. With the consent of the patient, the Clinic shall provide the third parties with the available written Information on the patient specified in the request, within the scope specified in the Consent.
6.2. In order to obtain written Information on the patient, the third party shall provide the Clinic with:
6.2.1. a written request stating the nature of the information requested and the purpose for which it is to be used (if the request is made by a legal person, the request must be signed by its manager or another person with the appropriate powers));
6.2.2. Consent, in the cases specified in clauses 6.3.2-6.3.4;
6.2.3. An identity document, if the request is sent by post or courier, a copy of this document, certified by a notary or lawyer shall be provided.
6.3. Patient may be issue a Consent to a third party for Information on the patient:
6.3.1. directly at the Clinic (before or after the provision of services), by entering the data of the person entitled to receive Information on the patient into the form (document) established by the Clinic and signing them;
6.3.2. by signing the Consent by certified e-mail. signature and sending it by e-mail. mail info@fiClinica.lt;
6.3.3. the insurance company in accordance with the applicable legal acts of the Republic of Lithuania or the relevant foreign state, performing life and/or health insurance activities, by filling in and signing the relevant documents of the insurance company;
6.3.4. a health care institution providing personal health care services to a health care institution in accordance with the applicable legal acts of the Republic of Lithuania or the relevant foreign state by filling in and signing the relevant documents of the health care institution.
6.4. The Clinic may refuse a third party’s request for Information on the patient if it is not possible to properly identify the identity of the person (patient) who signed the Consent and/or the authenticity of his/her signature.
7. PROVISION OF INFORMATION IN LEGISLATIVE PROCEDURE WITHOUT PATIENT CONSENT
7.1. Information on the patient available to the Clinic without the Consent of the Clinic may be provided to third parties only in accordance with the procedure established by legal acts and only to the extent that corresponds to the scope established by the request and legal acts.
7.2. Written information shall be provided to the following authorities without the written consent of the patient:
7.2.1. health care institutions where the patient is/has been treated, cared for or his/her health examination is performed;
7.2.2. institutions controlling health care services;
7.2.3. commissions for reviewing the condition of incapacitated persons for the performance of their functions;
7.2.4. court, prosecutor’s office, pre-trial investigation institutions;
7.2.5. municipal child rights protection departments;
7.2.6. civil servants of state social insurance fund administration institutions;
7.2.7. other institutions to which such a right is granted by the laws of the Republic of Lithuania.
7.3. When dealing with a patient’s complaint, when the complaint relates to the examination of Information on the patient that is confidential, the Clinic has the right to provide such confidential information to the Clinical Liability Insurance Institution and persons who directly examine the complaint.
7.4. Persons directly involved in the treatment or care of a patient performing a patient’s health examination without the patient’s consent Information on the patient may be provided in cases and to the extent necessary to protect the patient’s interests.
7.5. Private persons entrusted by the state with the performance of their share of functions (notaries, bailiffs, lawyers) and whose right to receive Information on the patient established by law is of a general nature, in the absence of a special, detailed legal provision on disclosure of specific patient confidential data. Patient Consent is not provided.
7.6. In order to obtain written Information on the patient the third party shall provide to the Clinic:
7.6.1. a written request stating the legal basis of the request, the nature of the requested information and the purpose of its use (when requested by the authorised state institutions, an original request, order, decision or other document signed by their head or authorised person shall be treated as their request);
7.6.2. documents confirming the right of persons to receive the requested information (e.g. court decision, etc.).
7.7. In all cases, the provision of confidential information must comply with the principles of reasonableness, fairness, the protection of patient’s rights and priority of interests.
7.8. In guaranteeing the patient’s right to privacy, the patient’s interests and well-being must take precedence over the public interest. The application of this provision may be limited in cases provided for by law where this is necessary for the protection of public security, the prevention of crime, public health or the rights and freedoms of others.
8. PROCEDURE FOR EXECUTION OF THE REQUEST
8.1. If, at the time of the request, when the request is submitted in person, the Clinic staff notices that the submitted request or documents are defective, it shall immediately inform the applicant and return the documents submitted to him/her for elimination of the defects.
8.2. Upon acceptance of the applicant’s request for Information on the patient, the Clinic employee shall register such request in the register of received documents (requests). If deficiencies in the request or other documents are identified, the responsible Clinic employee shall inform the applicant immediately, but not later than within 5 working days (within 3 working days if the request is made as a matter of urgency; within 1 working day where the patient submits a request to issue copies of medical documents) from the date of acceptance of the request, by sending a registered letter or by the e-mail address specified in the applicant’s request. Additional documents submitted by the applicant shall be registered in the register of documents (requests) received by the Clinic.
8.3. If the responsible person of the Clinic does not identify any deficiencies in the request or other documents, copies of the submitted documents shall be made and the documents shall be submitted to the relevant doctor who is treating or has treated the patient who attaches the documents received or copies thereof in the Form 003/a and/or 025-043a of the person about whom information is requested.
8.4. After evaluating the documents submitted by the applicant, the Clinic employee makes one of the following decisions:
8.4.1. satisfy the request;
8.4.2. refuse to comply with the request;
8.4.3. satisfy the request in part;
8.4.4. acknowledge that the Clinic does not have the requested information.
8.5. The decision to refuse to satisfy the request or to satisfy it in part must be reasoned and based on the grounds provided for in this Description or legislation. Information on the patient shall not be provided if this would be contrary to the principles of reasonableness, fairness and the protection of the patient’s rights and priority of interests.
8.6. If a decision is made to satisfy the request, the doctor who is treating or has treated the patient or other responsible employee of the Clinic prepares the requested information, signs and/or certifies copies of the documents and hands over the prepared documents to the receptionist of the Clinic. Copies of documents are certified as follows: “Genuine copy”, date, position, name, surname, signature.
8.7. The staff of the Clinic reception ensures that the documents are sent (handed over) to the applicant.
8.8. The written information prepared or the decision to refuse to provide the Information on the patient, transmitted to the applicant in person, acknowledging receipt of the information, shall be sent by courier or by registered mail. Information on the patient can only be provided by e-mail if the applicant’s request indicates that he or she wishes to receive the documents by e-mail and only by the e-mail address specified in his/her request.
9. DEADLINES FOR SUBMISSION OF INFORMATION
9.1. The deadlines for submitting written Information on the patient and refusing to provide it to the patient are calculated from the submission of all the documents required by the Clinic, as follows:
9.1.1. 10 working days;
9.1.2. 3 working days after submitting a written request for information “as a matter of urgency”;
9.2. The date of submission of information to the applicant or refusal to provide information shall be deemed to be the day when the information is personally served on the applicant, the information is transferred to the courier or sending by registered mail or is sent by the Clinic by electronic communication networks.
10. PROVISION OF INFORMATION BY TELECOMMUNICATIONS
10.1. Information on the patient by phone or e-mail is provided only if:
10.1.1. the patient has consented to be contacted by these means of communication;
10.1.2. the patient has provided the correct contact details and they match the contact person’s details;
10.1.3. the Clinic can properly identify the patient, his/her representative or another person who has the right to receive information in the cases specified in this Description;
10.1.4. written Information on the patient is encrypted and it is possible to pass the passwords and/or access codes required for decryption of the information to the patient, to his/her representative or the person entitled to receive the Information by other means of communication.
10.2. Where a request for information is made by a patient, his/her representative or a person entitled to receive Information on the patient by telecommunications, depending on the nature and extent of the information requested, the person requesting the Information on the patient shall be identified by one or more means of identification (the means of identification are chosen by the Clinic in each specific case):
10.2.2. The identity of the applicant shall be established by means of a questionnaire, provided that this information should be known only to the applicant.
10.2.3. The applicant signs the request by certified e-signature;
10.2.4. The applicant shall make a payment from a bank account opened in his/her name in a bank or other payment institution operating in the European Community to the bank account specified by the Clinic, the purpose of which is the code provided by the Clinic to identify the Applicant;
11. PECULIARITIES OF PROVIDING ORAL INFORMATION ON THE PATIENT
11.1. The patient, his/her representative, or the person to whom the patient’s Consent to receive Information on the patient has been given may be orally provided with Information on the patient’s medical condition, diagnosis, medical examination data, course of treatment.
11.2. The procedure for providing remote consultations and the related procedures and conditions for providing information to the patient are established in the rules of remote consultation of UAB Forma Perfecta.
11.3. Oral Information on the patient is provided immediately upon arrival at the Clinic or by telephone if the conditions in Chapter 10 are met.
12. FINAL PROVISIONS
12.1. All persons entitled to receive confidential written Information on a patient must maintain its confidentiality. Illegal collection and use of confidential Information on the patient is subject to liability in accordance with the procedure established by legal acts.