Form 1APPLICATION FOR ACCESS TO HEALTH RECORDS

PERSONAL DETAILS

Surname…………………………………….Date of Birth (DD/MM/YY)………………

Previous Surname (if applicable)…………...Address…………………………………….

First Name (s)………………………………………………………………………………

Is this your first application? YES/NO………………………………………………

If you answered NO what date did you last apply?……………………..Post Code…………….

………………………………………………..Contact Tel No………………………………

ACCESS REQUEST

Type of Request:

Please tick relevant box. Tick “View Health Records/Read Only” to view your health records. If you require a full copy of your health records please tick “Full copy of Health Records”.

View Health Records only‫Full copy of Health Records ‫

Please provide as much information as possible and specify if you only require a particular part of your health record. Please use another blank sheet if necessary.

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IDENTIFICATION

Please provide two types of identification i.e. passport, driving licence, birth certificate and additional proof of address i.e. bank statement, utility bill (Please do not provide originals).

THIRD PARTY DISCLOSURE

I hereby give permission to provide a copy of my health records to a third party.

Name of third party………………………………………………………………………………….

Please read notes overleaf. I have read this form and authorise a subject access request to be carried out. I understand that a fee may be required prior to release of any information.

Applicant’s signature…………………………………………Date………………………….

APPLICATION FOR SUBJECT ACCESS REQUEST (ACCESS TO HEALTH RECORDS)

The Data Protection Act 1998, which came in to force on 1 March 2000, allows you to find out what information about you is held on computer and in certain manual records. This is known as “right of subject access”. It applies to your health records. As the “holder” of your records Medwyn Surgery is known at the “data controller” and the patient is known as the “data subject” under the Act. The Act supersedes the previous rights for living patients under the Access to Health Records Act 1990.

Terms & Conditions

You are entitled to receive a copy but should note that a charge will usually be made. You should also be aware that in certain circumstances your right to see some details in your health records may be limited in your own interest or for other reasons. Medwyn Surgery has a written procedure which allows patients (data subjects) to access their health records.

Any information you have supplied in making this request will be treated in confidence. It will only be used for the purpose of carrying out the search for your information in accordance with Section 7 of the Data Protection Act 1998. Medwyn Surgery is only responsible for providing information which is held by us. If you feel you would like to discuss your information request further please telephone the Practice.

If your request indicates the release of information to a Third Party (e.g. solicitor, relative, insurance co.) please complete the relevant section.

If you are applying for access to your own records you will need to:

  • Complete this form
  • Provide two types of identification as well as provide proof of current address, if photocopies are provided with this form originals must be provided when colleting your information
  • An initial fee of £11 for administration will be charged. This can be paid by cash or cheque. Please make all cheques payable to Dr Monella & Partners.
  • There may be an additional charge upon collection of your health records to a maximum of £50 inclusive of your original £11 fee. The fee will be dependent on the amount of information and time taken to process your application.

Current Fees

Copies of computerised health records - £11.00

Copies of manual health records –up to a maximum of £50.00 (fee inclusive of any computerised records)

Access to view health records - £11.00

  • You do not need to give a reason to access your health records
  • Please provide as much information as possible
  • Please ensure that all information provided is accurate and up to date
  • Medwyn Surgery has 40 calendar days in which to respond to your request
  • If access has recently been given, access may not be given until a reasonable time interval has elapsed. What is reasonable depends upon the nature of the information, the purposes for which it is processed and when it was altered or added to.
  • There is no minimum age for applications. Children can apply for their own records provided they are capable of understanding the nature of the request.
  • A parent or guardian can only apply on a child’s behalf if (a) the child has given consent (b) the child is too young to have the understanding to make the request. Please note that a parent does not have a legal right of access to their child’s health records.