Application for Access to Medical Records

You have the legal right to request a copy of the information we hold about you, in line with the General Data Protection Regulation (GDPR).

We will normally be able to respond to your Subject Access Request within 28 days unless it is very complex information you are requesting in which case we will let you know of the delay. There is no charge for requesting access to your health data unless the request is deemed manifestly unfounded or excessive, or is a repetitive request.

Two documents need to be presented for a patient’s identity to be verified: one should be photo ID, and one showing your registered address dated within the last 3 months.

Subject Access Request

If you are human, leave this field blank.

Details of Patient / Clients / Staff Members Records To Be Accessed

Surname: *

Forename(s): *

Any former names (if applicable):

NHS Number (If known/relevant):

Current Address: *

Postcode: *

Previous Address (if applicable):

Postcode:

Details of Applicant

Are the applicant details different to the patients/clients/staff members details? *

Yes

Full Name: *

Company (if applicable):

Relationship with individual who’s records have been requested: *

Current Address: *

Postcode: *

Telephone Number: *

Details of Records to be Accessed

You do not have to give a reason for applying for access to your health records. However, to help the Practice save time and resources, it would be helpful if you could provide details below, informing us of periods and elements of your health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports etc.

Records dated from:

DD/MM/YYYY to DD/MM/YYYY

Department or services accessed:

Further details:

Records dated from:

DD/MM/YYYY to DD/MM/YYYY

Department or services accessed:

Further details:

Records dated from:

DD/MM/YYYY to DD/MM/YYYY

Department or services accessed:

Further details:

Authorisation to Release to Applicant

To be completed by the patients/clients/staff member if not making their own request.

I hereby authorise the surgery to release any personal data they may hold relating to me to the above applicant and to whom I authorise to act on my behalf.

Signature of patient / client / staff member: *

Date:

Declaration:

I declare that 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(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act.

Please select one box below: *

I am the patient/client/staff member (data subject).

I have been asked to act on behalf of the data subject and they have completed the authorisation section above.

I am acting on behalf of the data subject who is unable to complete the authorisation section above (I will upload/attach or provide to the practice in person a covering letter with further details).

I am the parent/guardian of a data subject under 16 years old who has completed the authorisation section above. (I will upload/attach or provide to the practice in person proof such as a birth certificate)

I am the parent/guardian of a data subject under 16 years old who is unable to understand the request and who has consented to my making the request on their behalf.

I have been appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order (I will upload/attach or provide to the practice in person proof of the order).

I am the deceased patient/client’s personal representative and attach confirmation of my appointment.

I have a claim arising from the patient/client’s death and wish to access information relevant to my claim (I will upload/attach or provide to the practice in person a covering letter with further details).

Sending Medical Records

Where possible, the surgery will send medical records electronically. Once an email leaves the NHS server, it is insecure. Therefore all medical records will be encrypted and password protected. The password will be provided in a separate communication.

I understand that my medical records will be emailed leaving the secure NHS network through an insecure network but will be encrypted and password protected and I am happy for them to be sent in this way.

Print Name: *

Signed (Applicant): *

Date:

Email address for records to be sent (if different to the one provided above):

Please note:

If you are making an application on the behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order etc.
It may be necessary to provide evidence of identity (i.e. Driving Licence).
If there is any doubt about the applicant's identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
Under the terms of the Data Protection Act, Subject Access Requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
If you are making a request under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client's record 40 days immediately preceding the date of this request, otherwise requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.
Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.

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 records referred to above under the terms of the Data Protection Act 2018.

Print Name: *

Signed (Applicant): *

Date:

Attachments

Please upload any relevant documents to support your request. If you are unable to do so, you will need to provide this to the practice in person.

Maximum upload size: 67.11MB

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Application for Access to Medical Records

Subject Access Request

Details of Patient / Clients / Staff Members Records To Be Accessed

Details of Applicant

Details of Records to be Accessed

Authorisation to Release to Applicant

Declaration:

Sending Medical Records

Attachments