Version 4

Date published: April 2016

Tel: 01494 782884 / Dr Rachael Morrell / Gladstone Surgery
Dr Katherine O’Brien / Chess Medical Centre
Dr Hardeep Bhupal / 260–290 Berkhampstead Road
Chesham HP5 3EZ

ARE YOU A CARER? CAN WE HELP?

Do you look after a family member, friend or neighbour who through illness, disability or frailty cannot manage without you? If so, you are a Carer and we would like to help.

Here at Gladstone Surgery we are aiming to identify all our patients who are Carers. We are keen to ensure that all Carers are aware of the help that may be available, both locally in Chesham and through speciality organisations and support services.

In this pack you will find 2 forms:

1)Carer’s Identification and Referral Form – Please complete this form and return it to reception. You will then be registered on our records as a Carer. With your permission we can also refer you to your local Carer’s Support Organisation. If you live in Buckinghamshire this will be Carers Bucks.

2)Carer’s Medical Record Access Agreement – You will need to give this form to the person you care for. By completing this form, the patient gives consent for their carer to access their medical records and information relating to their care eg test results. Please ask the person you care for if they wish to complete this form and return the completed form to reception.

Note the Carer’s Flexible Break scheme ceased from April 2016

Carers Support Group

In 2015 the surgery began hosting a Carers Support Group in conjunction with Carers Bucks. This group received so much interest that due to sheer volume of attendees it has now moved to the Town Hall. More information can be found on the carers notice board in main reception.

CARERS IDENTIFICATION AND REFERRAL FORM

DO YOU LOOK AFTER SOMEONE WHO IS

ILL, FRAIL, DISABLED OR MENTALLY ILL?

If so, you are a carer and we would like to support you. Please complete this form and hand it in to reception.

If you are agreeable, we will pass your details to the Carers Bucks Service, which is a local organisation providing relevant information and advice for carers.

YOUR DETAILS:

Name
Date Of Birth
Address
Post Code
Telephone Number
Any relevant information
GP Details / Gladstone Surgery, Chess Medical Centre
260 – 290 Berkhampstead Rd, Chesham, HP5 3EZ

DETAILS OF THE PERSON YOU LOOK AFTER:

Name
Date Of Birth
Address
(If Different From Above)
Post Code
Telephone Number
(If Different From Above)
GP Details
(If Different From Your Own)

□ Please fax my details to Carers Bucks on 01296 392466

SURGERY USE: When form is returned please fax to Carers Bucks on above number andread code carers record with 918A (Carer) and cared for patient as 918F (Has a Carer). Scan onto the record and forward a copy to GP via Docman.

Tel: 01494 782884 / Dr Peter Boast / The Gladstone Surgery
Dr Rachael Morrell / Chess Medical Centre
Dr Katherine O’Brien / 260–290 Berkhampstead Road
Chesham HP5 3EZ

AGREEMENT FOR A CARER TO HAVE ACCESS TO A PATIENT’S PERSONAL DETAILS and/or COPIES OF CORRESPONDENCE

Patient’s Name
Patient’s Address

To: Gladstone Surgery

I give permission for my Carer [ ] to have access to my medical records and personal details held by the Practice.

This permission relates to all / part of my record / specific condition only (delete as appropriate).

Where the permission is restricted to part of the record only, please specify below the precise limits of this permission, and any areas of the record which are excluded.

______

I understand that the doctor may override this authority at any time, and that this permission will remain in force until cancelled by me in writing.

I consent to my Carer receiving copies of all correspondence relating to my treatment (delete if not applicable). I confirm that this has been explained to me by my GP and that the GP has sole discretion to withhold all or any copies.

Signed ______(Patient)Date ______

Accepted by ______(Doctor)Date ______

SURGERY USE: When form is returned please read code carers record with 918A (Carer) and cared for patient as 918F (Has a Carer) and scan a copy of this form onto each record. Also add an alert onto the patients record containing name of their carer and the date patient consented to share information with their carer ie the date this form was completed.