Request For Access To Health Records

If you would like to request access to your own or someone else’s health records, please complete this form.

Request For Access To Health Records

Details of Patient / Clients Records To Be Accessed

Details of Applicant

Are the applicant details different to the patients/ clients details? *

Details of Records to be Accessed

Please select one of the following: *
DD/MM/YYYY
DD/MM/YYYY

Authorisation to Release to Applicant

To be completed by the patients/ clients if not making their own request.

*

Declaration:

I declare that the information given to me is correct to the best of my knowledge and that I am entitled to apply for access to health records under the provisions of the Data Protection Act 2018, and wish you to carry out my request as detailed on this form.

Please select one box below: *

Please note:

  • If you are making an application on the behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order etc.
  • It may be necessary to provide evidence of identity (i.e. Driving Licence).
  • If there is any doubt about the applicant's identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
  • Under the terms of the Data Protection Act, Subject Access Requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
  • If you are making a request under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client's record 40 days immediately preceding the date of this request, otherwise requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.
  • Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.

Attachments

Please upload any relevant documents to support your request. If you are unable to do so, you will need to provide this to the practice in person.
Maximum upload size: 67.11MB