Application for access to health records

Section 1 – Patient Details

Surname: *

Maiden Name:

First Name: *

Telephone Number:

Address:

Please include postcode.

NHS Number:

Hospital Number:

Section 2 – Record Request

Please tick the relevant boxes that apply.

Please provide me with a copy of all records held.

Please provide me with a copy of records between certain dates.

Please provide me with a copy of records relating to an incident.

Please give details of the incident: *

Please provide me with a copy of records relating to a condition.

Please give details of the condition. *

Section 3 – Details and Declaration of Applicant

Please enter details of applicant if different from Section 1.

Surname:

Forename:

Address:

Postcode:

Telephone Number:

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.

Please Select: *

I am the patient.

I have been asked to act by the patient and will provide the patient’s written authorization.

I have full parental responsibility for the patient and the patient is under the age of 18 and is either incapable of understanding the request, or has consented to my making this request.

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

I am 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 (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.

I have a claim arising from the person’s death.

Please provide details: *

Signed by Applicant: *

Date:

Section 4 – Proof of Identity

Please indicate how proof of ID will be confirmed: *

By bringing copies of documents as noted in section 4a below

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

Section 4a

Evidence of the patient’s and /or the patient’s representative identity will be required.

Please attach copies of the required documentation to this application form. Examples of required documentation are:

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

Section 4b

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, First Name: *

Certify that the applicant: *

For the below number of 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:

Full Name: *

Profession: *

Telephone Number: *

Address: *