APPLICATION FOR ACCESS TO MEDICAL RECORDS
Data Protection Act 1998 Subject Access Request

Details of the Record to be accessed:
Patient Surname	NHS Number
	
Forename(s)	Address

Date of Birth		

Details of the Person who wishes to access the records, if different to above:
Surname		
Forename(s)		
Address	

Telephone Number		
Relationship to Patient		

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 Data Protection Act 1998.

Tick whichever of the following statements apply.

o	I am the patient.

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

o	I am acting in Loco Parentis and the patient is under age sixteen, and is incapable of understanding the request / has consented to me making this request.
(*delete as appropriate).

o	I have parental responsibility either granted by the courts; or the child was jointly registered at birth with the mother (After 01 December 2003) (Proof will be required

o	I am the deceased patient’s Personal Representative and attach confirmation of my appointment.

o	I have a claim arising from the patient’s death and wish to access information relevant to my claim on the grounds that….(please supply your reasons below).
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

YOUR SIGNATURE: …………….…………………  DATE: …………………………….

One Month prior notice is usually required. You will be asked to provide identification when requesting this information.
 
Details of my Application 				
   
Patient to complete                                                    (please tick as appropriate)

I am applying for access to view my records only (either in an appointment setting or electronically via the NHS APP)		
I am applying for copies of my medical record		
I have instructed someone else to apply on my behalf		
I have attached the appropriate fee		

Notes:

Under the Data Protection Act 1998 you do not have to give a reason for applying for access to your health records. 

Optional - Please use this space below to inform us of certain periods and parts of your health record you may require, or provide more information as requested above.

This may include specific dates, consultant name and location, and parts of the records you require e.g. written diagnosis and reports. Note: defining the specific records you need may result in lower fee charges and a quicker response.

Please tick where appropriate
I would like a copy of all records
		
I would like a copy of records between specific dates only (please give date range) below

I would like copy records relating to a specific condition / specific incident only (please detail below)

		

PATIENTS NOTES

To view part or whole medical records:

The doctor will first assess your request and an appointment may be offered to suit the size or capacity of your medical records.  The doctor will be present at viewing to offer help if needed to interpret any medical terminology.  No fee will be charged for this service.     

Solicitors

Copies should not be requested if you are seeing a solicitor.  When you visit your solicitor, they will contact us for any information that they require and also cover any costs that are incurred.

Completing part C

If the patient is not capable of giving his or her consent, this form should be signed by:

•	The patient’s litigation friend (Solicitor)
•	Someone who has enduring power of attorney to act for the patient
•	The patient’s receiver appointed by the court of protection.
•	The patient’s parent or guardian if under 16 years old as long as they have parental responsibility 
•	The patient’s representative (friend or family)

All will require a signed declaration from the patient stating:
1.	Who they are (the patient)
2.	Who their representative is (name, address, relationship)
3.	What access they require the representative to have 
•	Verbal reading
•	View/sight of/complex reading/full access
•	Collect copies only

All representatives will require proof of identification. (passport, driving licence etc)