Application for Access to Health Records

Section 1 – Patient Details

Title: *
Please use date format DD/MM/YYYY
Any responses from the practice will go to this email address
Please include postcode.

Section 2 – Record Request

Please tick the relevant boxes that apply.
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Section 3 – Details and Declaration of Applicant

Please enter details of applicant if different from Section 1.
Title:

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: *

Section 4 – Proof of Identity

Please indicate how proof of ID will be confirmed: *

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.

e.g. employee, client, patient, relative etc.

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.

Please include postcode.

Additional Notes

Before returning this form, please ensure that you have:

  • signed and dated this form
  • can provide proof of your identity or alternatively confirmed your identity by a countersignature
  • can provide documentation and consent to support your request (if applying for another person’s records)

Incomplete applications will be returned; therefore please ensure you have the correct documentation before returning the form.