Request for Access to Records

Your Details

Full Name: *

Date of Birth: *

Email Address: *

Telephone Number:

NHS Number (if known):

Current Address (with postcode): *

Previous Address (if applicable):

Details of Records to be Accessed

In order to locate the records you require, please provide as much information as possible. Please list the department or services you have accessed that you require records from: e.e. PALS, complaints, continuing healthcare or Human resources etc.

Please include department of services accessed, including dates that you require the records to and from:

Details of Applicant (Complete if different to paitents/clients/staff members details):

Full Name:

Company (if applicable):

Relationship with individual who's records have been requested:

Address to which a reply should be sent (including postcode):

Authorisation to release to applicant (to be completed by the patients/clients/staff member if not making their own request)

I hereby authorise the practice 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:

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 terms of Access to Health Records Act (1990) / Data Protection Act.

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 ordered.
- It may be necessary to provide evidence of identity (i.e. driving license)
- 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, requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.
- Fore requests under the Access to Health Records Act 19990, requests will be responded to within 40 days where no entries have been made to the patient/clients 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, informaiton 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.

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 section 4 - authorisation above.

I am acting on behalf of the data subject who is unable to complete the authorisation section above.

I am the parent/guardian of a data subject under 16 years old, who has completed the authorisation section above.

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 requests on their behalf

I have been appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order (attached).

i am the deceased patient/client's personal representative, and attach confirmation of my appointment.

I have a claim arising from the patient/clients death and wish to access information relevant to my claim.

Signature: *

Date: *

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Your Details

Details of Records to be Accessed

Details of Applicant (Complete if different to paitents/clients/staff members details):

Authorisation to release to applicant (to be completed by the patients/clients/staff member if not making their own request)

Declaration

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