Access to Information Department
The RoyalLiverpool & BroadgreenUniversityHospital NHS Trust
Prescot Street
Liverpool
L7 8XP
0151 706 3232/2681
ACCESS TO PERSONAL DATA APPLICATION FORM
ACCESS TO HEALTH RECORDS ACT 1990/DATA PROTECTION ACT 1998
To access records for a living individual - Data Protection Act 1998.
To access records for a deceased patient - Access to Health Records Act 1990
Please complete in BLOCK CAPITALS and BLACK INK
Detailsof the person whose information is being requested
Mr, Mrs, Miss or Ms: ………………..DOB: ……………………………………..
Forenames: …………………………..Surname: ………………………………..
Address: ………………………………Contact Number: ……………………….
…………………………………………..Previous Surname: …………………….
…………………………………………..Previous Address: ……………………..
Postcode: ……………………………… ……………………………………………
……………………………………………
Applicant’s Details (if different to above)
Forename: …………………………………..Surname: …………………………………..
Relationship to Patient: …………………….
Address: ……………………………………..
………………………………………………...Postcode: ……………………………………
………………………………………………...Contact Number: …………………......
Please tick box/s below:
□I am the patient
□I am acting on behalf of the patient and they have completed the authorisation section
□I am acting on behalf of the patient who is unable to complete the authorisation section
□I am the deceased patient’s next of kin or personal representative
□I have a claim arising from the patient’s death and wish to access information relevant to my claim
Signature: …………………………………..Date: …………………………………
Details of the records you require
Health records dated from ___/___/______to ___/___/______
Give full details of all the episodes of treatment in which you are interested in, and if you only wish to receive data relating to a special aspect of an episode, please specify in the comments section:
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
…………………………………………………………………………………………..…………………………………………………………………………………………..…………………………………………………………………………………………..………………………………………………
Please note records will only be supplied up to the date this application form is completed. If any further records are required in the future a new application has to be submitted.
Are copies of x-ray films required?Yes/No
Please note copies of x-rays are available on CD Rom only
Details of the records you require
Information dated from: ____/___/______to ___/___/______
Please provide as much information as possible and give full details of any emails, HR records or personal information in which you are interested in below:
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
…………………………………………………………………………………………..………………
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Reason For Access(please tick)
□Complaint/Claim against Hospital
□Personal Use
□Other
Type of Request(please tick)
□I wish to view the Health Records at the Trust only
□I wish to receive copies of my records
Declaration
I declare that the information provided above is correct to the best of my knowledge
For the purposes of identity verification, can you enclose a copy of one the following forms of ID:
□Passport
□Driving Licence
□Birth Certificate
□BusPass
□Other (please state) ………………………………………………………………………..
On Collection:
Signed: …………………………...ID Checked:……………………
Print Name:……………………………Date:……………………
On receipt of this completed form a letter of acknowledgment will be sent to the applicant