Subject access request

Your Details

Home address (including postcode): *

Request Information

Which type of access do you require? *

Full medical record

Partial medical record

Please state what period your request covers or the relevant year(s):

Please briefly state the reason you require these records: *

Declaration By Applicant

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 under the terms of the Data Protection Act 1998 / Access to Health Records Act 1990.

Please select one of the following: *

I am the patient.

I have been asked to act by the patient and will provide the patient’s written authorisation.

I have been appointed by the court to manage the affairs of the patient and will provide confirmation of my appointment.

I have parental responsibility for the patient who is under 16 and they are not capable of understanding the request.

I have parental responsibility for the patient who is under 16 and they have consented to my making this request.

I am the deceased patient’s personal representative (executor/administrator) and will provide confirmation of my appointment, (NB. In the case of joint executors, all must sign below).

I have a claim arising from the patient’s death and will provide details and evidence of this claim.

I will provide all necessary evidence for this request and will present it at the practice.

Please also supply photocopies of identification documents including one form of photographic ID and proof of address.

Signature: *

Date:

Any information you have supplied in making this request will be treated in confidence. It will only be used for the purpose of carrying out your request in accordance with the Data Protection Act 1998 or Access to Health Records Act 1990. After your request is completed your information will be retained for a statutory time period (currently 6 years), after which date it will be securely destroyed.

Additional Signatures

Signature: *

Date:

Signature: *

Date:

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Your Details

Request Information

Declaration By Applicant

Additional Signatures