Subject Access Request Form

If you wish to request access to your health records, please complete this form.

Please note you must provide any necessary evidence for the request to be approved. This can be presented at the practice.

Subject Access Request

Subject Access Request

Your Details

Request Information

Which type of access do you require? *

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 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.

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.

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