Access to Medical Records

Details of the Records to be Accessed:

Patient Name *

Date of Birth *

Email address *

NHS Number

Address

Full Postcode

Telephone Number

Previous address if applicable:

Are you requesting access to your own medical record? *

Yes

No

Details of the Person who wishes to access the records, if different to above:

Name *

Address *

Telephone Number

Relationship to Patient *

*

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 records referred to above under the terms of current Data Protection Legislation.

Please select one of the following statements: *

I am the patient

I have been asked to act by the patient. We will in all instances seek independent authorisation/verification by the patient before releasing any data, to a third party, unless required to so by Law.

I am acting in Loco Parentis and the patient is under age sixteen, and is incapable of understanding the request / has consented to me making this request. (*delete as appropriate).

Your Signature *

Date

Details of my Application

Please Note:

If you are making an application on behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order, statutory requirement etc.
It may be necessary to provide evidence of identity.
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 current Data Protection Legislation requests will be responded to within 30 days after receiving all necessary information to process the request.
Under Data Protection legislation, Information disclosed under a Subject Access Request may have certain 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.
In all cases your GP will be asked to authorise the release of your records, and may in certain circumstances retain information where it is deemed may harm the patient.
We do not hold records for deceased patients these can be accessed via NHS England at the following pcse.england.nhs.uk.
There is no charge for providing your copy records; however we may make a charge for subsequent or repeated requests.

Under current Data Protection Legislation you do not have to give a reason for applying for access to your health records. However providing medical records is a time consuming exercise, for which we have limited resource available. To help us please use this space below to inform us of certain specific periods and parts of your health record you may require.

This may include specific dates, consultant name and location, and parts of the records you require e.g. written diagnosis and reports. Note: defining the specific records you need may allow us to provide a quicker response.

Please tick as appropriate:

I am applying for access to view my records only

I would like a copy of all records

I would like a copy of records between specific dates only (please give date range below)

I would like copy records relating to a specific condition / specific incident only (please detail below)

Please provide specific dates: *

Please specify the condition / incident: *

*

I confirm that the information provided is accurate to the best of my knowledge and that my enquiry is not urgent

Application for Access to Medical Records

Details of the Records to be Accessed:

Details of the Person who wishes to access the records, if different to above:

Details of my Application

New Patient Registrations

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Access to Medical Records

Application for Access to Medical Records

Details of the Records to be Accessed:

Details of the Person who wishes to access the records, if different to above:

Details of my Application

New Patient Registrations