Access to Medical Records form

Section 1: Patient Details

Please state:

First Name *

Surname *

Phone Number

Address

Please include postcode

NHS Number (if known)

Hospital Number (if known)

Section 2: 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 below:

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

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

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

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

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

Section 3: Details and declaration of applicant

Please enter details of applicant id different from Section 1

Please state:

First Name

Surname

Phone Number

Address

Please include postcode

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 the GDPR.

I am the patient

I have been asked to act by the patient and have the patients written authorisation

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

a) has consented to my making this request, or

b) is incapable of understanding the request

I have been appointed by the court to manage the patient's affairs and can produce on request 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 can provide confirmation of my appointment on request (Grant of Probate/Letters of Administration)

I have written, and witnessed, consent from the deceased person's Personal Representative and can provide Proof of Appointment on request

I have a claim arising from the person's death

Please give details:

Signature of applicant *

Date

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.

Section 4: Proof of identity

Please indicate how proof of ID will be confirmed

Copies of documents will be provided as noted in Section 4A below

Countersignature (section 4B). This should only be completed in exceptional circumstances (e.g. in cases where the above cannot be provided)

Please indicate reason why this section was completed:

Section 4A: Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required.
You will be required to provide copies of the require documentation to this application form, these will need to be brought into the practice.

Examples of required documentation are:

	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)

Section 4B: Contersignature

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 4A cannot be fulfilled.

I (insert full name)

Certify that the applicant (insert full name)

Has been known to me personally as...

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

for this many years...

...and that 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

Profession

Daytime telephone number

Address:

please include postcode

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 2 working days before I receive a reply.

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