Application for Access to Health Records
Please complete this form in BLOCK CAPITALS and in black ink, and hand it to the
Receptionist,along with a copy of one of the following Acceptable proof of identity:
- Passport (copy of photo page)
- Driving licence (photo-card)
Patient Details
Surname……………………………………. Forenames: …………..…………………………….
Any former names …………………………………………………………………………………..
Date of Birth: ……………………………… NHS Number: …………………………......
Current Address:…………………………………………………………………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Telephone Number: ……………………………………………………………….………………..
Previous Address (if changed recently):………………………………………………………….
…………………………………………………………………………………………………………
Email address ………….……………………………………………………………………………
Please tick the box below which applies:-
I am applying for a copy of my health records
I am applying for access to view my health records
(If you wish to view your records an appointment will be arranged for you with The Practice Support Officer to do this.)
Details of the information required
Please provide us with dates, Practice Consultations/ hospitals / clinics / wards and health professionals involved in yourcare (if known) which are of interest to you. Please provide dates of test results ect that you are interested in. Please provide as much information as possible toassist us in locating the information from your health records that you would like to access.
Health records covering the period:
Date from: ………………………………… Date to: .....……….…………………………………
Practice Consultations/Hospital / Clinics / Wards of interest: ……………………….………….
…………………………………………………………………………………………………………
Health professionals’ records of interest: .....…………………………………………………….
…………………………………………………………………………………………………………
Additional areas of interest (test results ect)..……………………………………………………..
…………………………………………………………………………………………………………
You will be given access to your medical records for a period of 28 days. PLEASE MAKE SURE YOU HAVE FILLED IN A “SIMPLE ONLINE ACCESS REQUEST FORM” TO ENABLE US TO GIVE YOU ACCESS. You will be informed when you are able to access your full medical records.
- Patient Declaration and Authorisation:
I am applying to access my health records under the Data Protection Act 1998
I declare that the information I have completed on this form is correct to the best of my
knowledge and that I am the person named overleaf.
The introduction of General Data Protection Regulation (GDPR) has brought changes to patient’s medical access requests. As of 25th May 2018, the Practice will be unable to charge for copies of a patient’s records (whether the request is made by a patient or third party representative), unless the request is excessive. In this case, a reasonable fee can be charged of up to £50. Under GDPR, the timescale allowed to deal with patient’s medical record requests is 30 days.
I declare that the information I have completed on this form is correct to the best of my
knowledge and that I am the person named overleaf.
Your name in BLOCK CAPITALS…………………………………………………
Signed…………………………………………… Date……………………………
If you are an authorised representative of the patient, please complete Box B and obtain the
patient’s signed authorisation or supply copies of documents giving you right of access under the
Mental Capacity Act.
If you are a relative or other person applying for access to information in relation to a deceased
patient’s records please complete Box C.
- Representative of Patient – Declaration and Authorisation:
I am applying to access my health records under the Data Protection Act 1998
I declare that the information I have completed on this form is correct to the best of my
knowledge and that I am the person named overleaf
The introduction of General Data Protection Regulation (GDPR) has brought changes to patient’s medical access requests. As of 25th May 2018, the Practice will be unable to charge for copies of a patient’s records (whether the request is made by a patient or third party representative), unless the request is excessive. In this case, a reasonable fee can be charged of up to £50. Under GDPR, the timescale allowed to deal with patient’s medical record requests is 30 days
Your name in BLOCK CAPITALS…………………………………………………………
Signed…………………………………………… Date…………………………………..
Your relationship to the patient……………………………………………………………
I, the patient, agree to the above named being supplied with a copy of my health
records:
Patient’s signature………………………………………………………………………
C. Disclosure of records of a deceased patient
I am applying for access to the deceased patient’s health records.
Your name in CAPITAL LETTERS: …………………………………………………...
Youraddress…………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Signed…………………………………………
Date…………………………………………..
Your relationship to the deceased patient: ……………………………………………………..
I am the executor / personal representative of the deceased patient’s estate - Yes / No
If yes, please provide copy of evidence
I have a claim arising out of the death of the deceased person - Yes / No
If yes, provide details of the claim which may arise