Application for Subject Access Request

(Living Person)

1

v8 December 2016

Access to Health Records under the Data Protection Act 1998

(Subject Access Request for Living Person)

Patient’s authority consent form for release of health records

(Please print all details and use dark ink)

Identity of individual about whom information is requested

Full Name / Former name(s)
Address / Former addresses (with dates of change)
Date of birth / NHS Number (if known)
Contact phone number (including area code) / E-mail address (optional)

Please tick the appropriate box:

I am applying to access my health records
I have been asked to act by the patient and attach the patients written authorisation
I am the patients parent/legal guardian (with parental responsibility)
I have been appointed as the Mental Capacity Advocate for the patient and wish to access copies of their records. I attach confirmation of my appointment.
Other? Please state:

Name:…………………………………………………………………………………………

Date:……………………………………………………………………………………………

Signature of Patient: (where applicable)…………………………………………

What is being applied for (tick as applicable)? In doing so you understand you will have to pay a fee for access or copies of your records.

I am applying for access to view health records in paper format (Monday to Friday 8am – 5pm)
I am applying for access to view health records online in electronic format (Monday to Friday 8am – 5pm)
I am applying for copies of health records (including black and white copies of any photographs)

Please tick all relevant boxes to indicate the types of records you wish to access

County Durham & Darlington NHS Foundation Trust Hospital Health Records (Inpatient and Outpatient)  / Speech & Language Therapy
Accident and Emergency Records / Podiatry
Physiotherapy Records/Orthotics Records
(delete where applicable) / Dietician
Urgent Care /Out of Hours/Minor Injury Records / Genitourinary Medicine and Sexual Health 
Radiology (including report) 
X-ray/MRI/CT/Ultrasound (delete where applicable) / Audiology/Ophthalmology (delete where applicable) 
Colour Clinical Photographs / Community Records (for example, district nurse,
Palliative care, midwife) 

You do not have to give a reason for applying for access to your health records. However, to help the NHS save time and resources, it would be helpful if you could provide details below, informing us of periods and parts of your health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports, etc. Please use the space below to document and continue on another page if necessary:

If you are the patient’s representative please give details here

Name and address of representative:
Contact number and e-mail
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 in this request, under the terms of the Data Protection Act 1998
Signature of applicant:……………………………………………
Print name:…………………………………………………………
Date:…………………………………………………………………

Please make sure you have:

  • Completed this form in full
  • Signed the declaration above
  • Enclose the relevant proof of identity
  • If applying on behalf of another person, their permission together with any authorities to act on their behalf
  • Completed the quick feedback section below

Send the completed form and enclosures to:

Access to Health Department

County Durham and Darlington Foundation Trust

Appleton House

Lanchester Road

Durham

DH1 5XZ

We would appreciate feedback on how satisfied you were with this process

PLEASE TICK ONE BOX FOR EACH QUESTION:

1) It was easy to locate this booklet to request the information.

Strongly Agree Agree Neither Disagree/Agree Disagree Strongly Disagree

2) The charging structure for receiving the information is clear

Strongly Agree Agree Neither Disagree/Agree Disagree Strongly Disagree

3) It is easy to indicate what information I require from the different types of records

Strongly Agree Agree Neither Disagree/Agree Disagree Strongly Disagree

4) I felt confident and was treated with respect and dignity by the Access to Health Team when I contacted them.

Strongly Agree Agree Neither Disagree/Agree Disagree Strongly Disagree

1

v8 December 2016