Access to medical records

Details of Applicant

Full Name:

Company (if applicable):

Relationship with individual who’s records have been requested:

Telephone Number:

Email Address:

Address (including postcode):

Details of Patient/Clients/Staff Members records to be accessed

Complete if different from Applicant

Surname:

Forename(s):

Any former names (if applicable):

Telephone Number:

NHS Number (if known/relevant):

Current Address (including postcode):

Previous Address (if applicable):

If further details are available, please provide us with a separate covering note.

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: i.e. PALs, complaints, continuing healthcare or Human resources etc.

Records dated from:

To:

Department/Services accessed:

Authorisation to release to applicant

To be completed by the patients/clients/staff member if not making their own request.

I hereby authorise Stow Surgery to release any personal data they hold relating to me to the above applicant and to whom I authorise to act on my behalf

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

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 (Covering letter with further details to be supplied).

I am the parent/guardian of a data subject under 16 years old who has completed the authorisation section above. (Please include proof such as birth certificate)

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 the request on their behalf.

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

I am the deceased patient/client’s personal representative and attach confirmation of my appointment.

I have a claim arising from the patient/client’s death and wish to access information relevant to my claim (Covering letter with further details to be supplied).

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 order etc.
– It may be necessary to provide evidence of identity (i.e. Driving Licence).
– 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.
– For requests under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client’s 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, Information 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.

Tell us whether you accept cookies

Access to medical records

Details of Applicant

Details of Patient/Clients/Staff Members records to be accessed

Details of Records to be Accessed

Authorisation to release to applicant

Declaration