Inpatient/Daycase Waiting List As at 5 May 2006-05-16

Application for Subject Access Request (Deceased Person)

Access to Deceased Patients Health Records under the Access to Health Records Act 1990

(Please print all details and use dark ink)

Please provide details of the patients GP name and address or consultant name and hospital department

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)

Requestor information (tick as applicable)? In doing so you understand you may have to pay a fee for access or copies of the records.

I am the deceased persons representative applying to accesstheir health records
I have a claim arising from the death of a deceased person and require access to their records

Details of person requesting the information

Surname…………………………………………………………………….

Forename(s)…………………………………………………………………

Address………………………………………………………………………

………………………………………………………………………………..

Telephone number…………………………………………………………

Relationship to patient…………………………………………………….

I am the deceased person’s personal representative and attach a copy of confirmation of my appointment: (Indicate below)

Letter of Administration
Grant of Probate
Patients Will

I have a claim arising from the patient’s death (please provide details of this claim below and provide documentary evidence):

……………………………………………………………………………………………………

What is being applied for (tick if applicable)? In doing so you understand you may have to pay a fee for access or copies of the record.

I am applying for access to view paper health records in paper format (Monday to Friday 8am – 5pm)
I am applying for access to viewhealth 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) 

Please refer to the guidance booklet on page 3 for pricing structure.

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 the health record 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:

Dates and types of records:

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 the access to the health records referred to in this request, under the terms of the Access to Health Records Act 1990.

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

v8 December 2016