Application for Access to Personal Records

Application for access to personal records

(under the subject access provisions of the Data Protection Act 1998)

The Leicestershire Partnership NHS Trust provides a wide range of services in a variety of settings and, as such,your information may be held on one or more sites. To help us deal with your request, please provide as much information as possible.

Section A– Information about the person whose health records are being requested.

Name:
Any other name(s) the person was, known by: (For example previous surnames, or names the patient preferred to be known as).
Date of birth:
Current home address: (with postcode)
Day time telephone number:
Previous addresses: (with postcode)
Assignment Number: (if known)
Please give as much information as possible about the records you wish to have access to, in order to help us identify their location:
Please tick what type of records access is being requested for; / Paper records  / Electronic records  / Both 
(records held on computer)

Proof of the patient’s identify must be included with this application form, for example a photocopy of a driver’s licence, birth certificate, passport etc.

Section B – to be completed by the person making the request

I declare that the information in this form is correct to the best of my knowledge and that: (please tick and complete as appropriate)

I am the data subject

I have been asked to make this application by the data subject

(Please complete your details below; you must also attach written confirmation of your appointment)

Name of person making the request:
Address: (with postcode)
Day time telephone number:

Signed: ……………………………………………………………………. Date: …………………………………….

Section C – Certification of the applicant

Name:
Address: (with postcode)

I have known the applicant for ….. years. The applicant is known to me under the above name as an employee / client / personal friend and I have witnessed the applicant sign this form.

Signed: …………………………………………………………………… Date: …………………………….

This completed application form should be returned to:

Subject Access Requests,

Information Requests Team,

Suite P1, Bridge Park Plaza

Bridge Park Road, Thurmaston

Leicester, LE48BL

Once we have received this completed application form, you will hear from us about your request for access to records within the next 40 days. All correspondence will be sent to the address of the applicant

There may be a charge for receiving copies of your records and we will notify you of this once your records are available.In cases of hardship, such as unemployment or claiming benefits, it may be possible to waive the fee. Please contact the team to discuss, if you believe this may apply to your situation.