Access to Health Records Office Health Records Department
Calderdale Royal Hospital
Salterhebble Hill
Halifax
HX3 0PW
Tel: 01422 222065 Fax:01422 222412
Date:
Dear Sir/ Madam
Further to your recent enquiry about inspecting hospital medical records, or requesting copies of them, I would be grateful if you would complete and return the attached form.
The purpose of this form is to help us to identify the records you wish to access. It also allows us to preserve patient confidentiality by ensuring that hospital records are divulged only to the appropriate applicant. In certain circumstances we may wish to contact the witness who has certified your application as legitimate.
There is a charge payable for this service, which varies according to the type of access you require and the category of records requested:
Access to your own medical records under the Data Protection Act 1998
If you require copies of an A & E attendance only, with no follow-up treatment involved, the cost will be £10. If you require copies of in-patient or out-patient treatment, including any associated A & E attendance, the cost will be £50. These charges include postage.
If you wish simply to inspect your own records, with no copies provided, the charge will be £10. If, after inspection, you wish to order copies, the above charges will apply. The £10 inspection fee will not be charged if your records have been updated within the last 40 days, e.g. as the result of any hospital treatment. In that case you may inspect your records free of charge, but any copies requested will be charged at the above rates.
Access to a deceased patient’s records under the Access to Health Records Act 1990
For the supply of copies there is a basic £10 administration fee, plus photocopying charges (currently 20 pence per sheet) and postage at cost. If the patient has died within the last 40 days the £10 administration fee will not be charged, but the photocopying and postage charges will apply.
If you wish simply to inspect the records of a deceased patient the £10 administration fee applies, unless the patient has died within the last 40 days. In that case you may inspect the record free of charge.
Under either type of request we will advise you of the cost and request payment once your application has been received and initially reviewed this will be prior to processing the full request.
All copies will be supplied on a C.D unless otherwise specified.
If you need any further help or information, please contact the Access to Data Office at the above address or telephone number.
Access To Health Records Team
Health Records
APPLICATION FOR ACCESS TO HEALTH RECORDS
(Data Protection Act 1998& Access to Health Records Act 1990)
SECTION ONE - Details of record to be accessed
PATIENT:
Surname ......
Forename(s) ......
Title (Mr./ Mrs./ Miss/ Ms./ Dr./ Other) ......
Address ......
...... Postcode ......
Telephone ...... Date of birth ......
RECORDS:
Name of hospital/ clinic/ surgery ......
Approximate date of treatment ......
Nature of illness/ accident ......
Name of consultant, doctor or other health professional providing treatment (if known)
......
I would like *copies of the casenotes / to view the original casenotes (delete as required)
* All copies will be supplied on a C.D unless otherwise specified.
SECTION TWO – Application by someone other than the patient
(Please complete this section if you are not the patient identified in Section One. Please also check in Section Three to see if you need to provide any documentary evidence).
Surname ......
Forename(s) ...... Title ......
Address ......
...... Telephone ......
SECTION THREE - Declaration of applicant
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 or the Access to Health Records Act 1990.
Please indicate in which capacity you are making this application:
- I am the patient.
- I have been requested by the patient to make this application and I enclose the patient’s written authorisation.
- I hold an enduring power of attorney over the affairs of this patient and I enclose a copy of the authority.
- I am acting in loco parentis. The patient is under the age of 16 and is either incapable of understanding this request or has consented to my application.
- I am the deceased patient’s personal representative. (Please indicate your relationship to the deceased patient, e.g. spouse, parent, child, legal executor. Please provide legal proof, e.g. copy of will, certificate of probate, official letter from a solicitor). I am applying in my capacity as the deceased patient’s ...... and I enclose ...... in support of my application.
- I have a claim arising from the patient’s death and wish to access information relevant to that claim on the following grounds : ......
Signature ...... Date ......
SECTION FOUR - To be completed by a responsible adult who knows the applicant
Surname ...... Forename(s) ......
Address ......
...... Telephone ......
I certify that I have known the applicant for ...... years as a ......
(e.g. friend/ colleague/ employer) and I have witnessed the applicant sign this form.
Signature ...... Date ......