Subject Access Request Template

Patient’s authority consent form for release of health records

To: (Please provide GP name, Practice address and contact details here)
Testvale Surgery
12 Salisbury Road
Totton
Southampton
SO403PY

Identity of individual about whom information is requested

Full name / Former names (s)
Current address / Former address (with dates of change)
Date of birth / NHS Number (if known)
Contact phone number (including area code) / E-mail address :

What is being applied for (tick as applicable). In doing so you understand you may have to pay a fee for access or copies of your records.

I am applying for access to view my health records
I am applying for copies of my health record

Please provide details below informing us of periods and elements of the health records you require, along with details which you may feel have relevance (such as consultant name, location, written diagnosis and reports etc) Please also request a specific time period for the records you wish to see:

Dates and types of records:

Please tick the appropriate box identifying whether you or a representative on your behalf is applying for access.

I am applying to access my health records
I have instructed my authorised representative to apply on my behalf

If you are the patient’s representative please give details here:

Name and address of representative
Relationship to patient
Contact number and email
Signature:
Signature of applicant:
Print name:
Date:

OFFICIAL USE ONLY

Date application received: / Application received by:
Signed: / Date:

Verification checks:

Confirmation of receipt

Have you sent a confirmation of receipt to the applicant informing them the application has been received and their data is being processed? / Yes / No

Identity of Applicant

Have you asked the requestor for evidence to confirm their identity? Please confirm this has been carried out. / Yes / No

Does the information requested reference other people in the medical record?

Do not supply the information unless the other people mentioned have given their consent for the disclosure, or it is reasonable to supply the information without their consent. / Yes / No

Check whether the practice is obliged to release the information?

Is the information the requestor wants exempt from Subject Access? / Yes / No

Does the information contain any complex terms or codes?

Ensure that the terms or codes are explained, so that the information can be understood or provide a copy of the information in a permanent form / Yes / No

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