Application for access to health records by a patient or representative

Section 1: Patient details

Patient details

Required
Required
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Address Required

Applicant details (if different from above)

Address

Section 2: Request details

Please tick, if any of the following that apply
I am applying to

Please note that records will be provided on CD/DVD or via a secure email unless specifically requested otherwise.


Section 3: Declaration

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record referred to above under the terms of the General Data Protection Regulation/Data Protection Act 2018 and Access to Health Records Act 1990 on the grounds that: (please tick the appropriate box)

I am the patient and am applying for a copy of my health record.
I represent the patient and consent has been granted (please attach or fill in authorisation section below)
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.
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.