Access To Health Records Request

Section

Applicants Address:

Applicants Postcode:

Applicants NHS Number:

Applicants Hospital Number:

Record Requested

The more specific you can be, the easier it is for us to quickly provide you with the records
requested. Record in respect of treatment for: (e.g. leg injury following a car accident).

Please provide me with a copy of all records held:

Please provide me with a copy of records between the dates specified:

Please provide me with a copy of records relating to the incident specified:

Please provide me with a copy of records relating to the condition specified:

Declaration of Applicant

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

*

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 GDPR.

Please specify:

I am the patient

I have been asked to act by the patient and attach the patient’s written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18

I have been appointed by the court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so

I am acting in loco parentis and the patient is incapable of understanding the request

I am the deceased person’s Personal Representative and attach confirmation of my appointment (Grant of Probate/Letters of Administration)

I have written, and witnessed, consent from the deceased person’s Personal Representative and attach Proof of Appointment

I have a claim arising from the person’s death

I have full parental responsibility for the patient and the patient is under the age of 18 and:

Has consented to my making this request

Is incapable of understanding the request

Signed:

Date:

Proof of Identity

Method in which identity is confirmed:

Email copies of the documents; the practice will be in touch to confirm the practice email address.

Yes

No

Please confirm which documents you will be emailing: *

Countersignature; this should only be completed in exceptional circumstances (e.g. in cases where the above cannot be provided)

Yes

No

Please indicate the reason why this section was completed: *

Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required. Please email the practice with copies of the required documents. Examples of required documentation are listed below:

	Type of applicant	Type of documentation
A	An individual applying for his/her own records	One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc.
B	Someone applying on behalf of an individual (Representative)	One item showing proof of the patient’s identity and one item showing proof of the representative’s identity (see examples in ‘A’ above)
C	Person with parental responsibility applying on behalf of a child	Copy of birth certificate of child & copy of correspondence addressed to person with parental responsibility relating to the patient
D	Power of Attorney/Agent applying on behalf of an individual	Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)

Countersignature

This section is to be completed by someone (other than a member of your family) who
can vouch for your identity. This section may be completed if the Evidence section above cannot be fulfilled.

I (Full Name):

Certify that the applicant (Full Name):

Please confirm what the applicant is personally known to you as and for how many years:

(Insert in what capacity, e.g. employee, client, patient, relative etc.)

I have witnessed the signing of the above declaration. I am happy to be contacted if further information is required to support the identity of the applicant as required.

Signed:

Date:

Full Name:

Profession:

Daytime Telephone Number:

Address:

Incomplete applications will not be processed.

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Section

Record Requested

Declaration of Applicant

Proof of Identity

Method in which identity is confirmed:

Evidence

Countersignature