The form is for patient and family / guardian representative use only. Legal representatives should contact our team directly via the details below:

Application for access to health records by a patient or representative

Section 1: Patient details

Patient details

Required
Required
Invalid date
Address Required

Applicant details (if different from above)

Address

Section 2: Request details

Please select, if any of the following that apply
I am applying to
Select one of the following:
I have parental responsibility for the patient and am acting in loco parentis. The patient is under the age of 18 and is either incapable of understanding the request or has consented to my making the request.
I am the deceased patient’s personal representative, executor or have a claim arising from the death and attach the relevant documents.

Section 3: the patient's scanned signature

Required
Required
Invalid date

Section 4: Authorisation to grant access to a representative

I authorise the representative, named above to apply for access to my health record under the Data Protection Act 1998.

Required
Required
Invalid date

Section 5: Identification

In order to process your request we require proof of identification. Please attach a copy of your passport, driver’s licence or other valid identification, as well as a proof of address. If you are applying for access on behalf of the patient you will need to provide proof of your identity as well as that of the patient, as well as any other required legal documents. 

Required

Section 6: Charges for copied records

There is no fee for subject access requests. However, if the request is excessively large or for repeated requests there may be an administrative fee to pay. If this is the case, we will contact you to let you know.

Privacy policy Required

Our privacy statement explains how we protect any sensitive information you provide us with, and how we use information gathered while providing your healthcare.