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Medical Declaration Form for the Netherlands

Medical Declaration Form Template for Netherlands

A standardized medical declaration document compliant with Dutch healthcare legislation, including the Medical Treatment Agreement Act (WGBO) and General Data Protection Regulation (AVG/GDPR). This form serves as an official medical statement documenting a patient's health status, conditions, or fitness for specific purposes. It includes sections for personal information, medical professional details, relevant medical history, current health status, and formal declarations, all structured to meet Dutch legal requirements for medical documentation and data protection.

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What is a Medical Declaration Form?

The Medical Declaration Form is a crucial document in the Dutch healthcare system, used to formally document and communicate a patient's medical status or fitness for specific purposes. This document is required in various contexts, including employment assessments, insurance claims, educational institutions, sports participation, or travel clearance. The form must comply with Dutch healthcare legislation, particularly the Medical Treatment Agreement Act (WGBO) and privacy laws (AVG/GDPR). It contains detailed medical information, professional assessments, and necessary declarations while ensuring patient privacy and data protection. The Medical Declaration Form serves as an official medical statement and may be requested by various organizations or institutions requiring formal medical documentation.

What sections should be included in a Medical Declaration Form?

1. Personal Information: Patient's identification details including full name, date of birth, BSN number, contact information, and insurance details

2. Medical Professional Information: Details of the examining physician or healthcare provider, including name, BIG registration number, and institution

3. Medical Declaration Purpose: Clear statement of the purpose for which the medical declaration is being made

4. Medical History: Relevant medical history and current health status related to the declaration purpose

5. Current Medical Status: Statement of current medical condition or findings relevant to the declaration

6. Declaration Statement: Formal medical declaration based on the examination and findings

7. Data Processing Consent: GDPR-compliant consent section for processing medical data

8. Signatures: Signature fields for the medical professional, patient, and date of signing

What sections are optional to include in a Medical Declaration Form?

1. Third Party Authorization: Section for authorizing disclosure to specific third parties, used when the declaration needs to be shared with other organizations

2. Research Participation: Additional section for consent to use data in medical research, required when the declaration may be used for research purposes

3. Specialist Referral Details: Section for including information from specialist consultations, used when the declaration requires input from multiple medical professionals

4. Translation Declaration: Section certifying that the contents have been explained in patient's preferred language, used for non-Dutch speaking patients

5. Emergency Contact: Section for emergency contact information, included when required by the requesting organization

What schedules should be included in a Medical Declaration Form?

1. Medical Examination Results: Detailed results of specific medical examinations or tests relevant to the declaration

2. Supporting Documentation List: List of all medical documents and test results reviewed in making the declaration

3. Privacy Notice: Detailed information about how the medical data will be processed, stored, and shared

4. Rights and Obligations: Summary of patient's rights and obligations under Dutch healthcare laws

Authors

Alex Denne

Head of Growth (Open Source Law) @ Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Jurisdiction

Netherlands

Publisher

Ƶ

Document Type

Declaration Form

Cost

Free to use
Relevant legal definitions



























Clauses




















Relevant Industries

Healthcare

Insurance

Education

Employment

Sports & Recreation

Transportation

Immigration

Legal Services

Occupational Health

Public Administration

Relevant Teams

Human Resources

Medical Administration

Compliance

Legal

Privacy & Data Protection

Operations

Quality Assurance

Customer Service

Documentation

Risk Management

Relevant Roles

Medical Doctor

General Practitioner

Medical Specialist

Occupational Health Physician

Insurance Medical Advisor

Healthcare Administrator

Compliance Officer

HR Manager

School Administrator

Sports Administrator

Immigration Officer

Legal Counsel

Privacy Officer

Medical Records Manager

Industries






Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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