Application for access to medical records

*

I confirm that I have read the Subject Access Request information page.

Details of the Records to be Accessed

Section

NHS Number:

Address including postcode: *

Are you requesting access to your own medical records? *

Yes

No

Please select one of the following statements: *

I am parent/guardian and the patient is under sixteen and is incapable of understanding the request.

I have been asked to act by the patient. The practice will require signed consent by the patient before releasing any data to a third party unless required to do so by law.

Name of handler of company requesting records:

Full address including postcode of company requesting records:

Required information (and any relevant dates):

Example: Copies of medical records for the last 5 years

By completing this form, you are making a request under the General Data Protection Regulation (GDPR) for information held about you (the patient) by the practice that you are eligible to receive.

By signing below, you indicate that you (the patient) are the individual named above. The practice cannot accept requests regarding your personal data from anyone else, including family members, without verification.

Data subject signature: *

Date:

We will need to verify your (the patient’s) identity before information can be released. This should ideally be photographic ID.

If you are unable to provide photographic ID, two forms of non-photographic ID can be accepted e.g. bank card/utility bill.

Once you have submitted this form you will receive a link allowing you to send ID.

Tell us whether you accept cookies

Details of the Records to be Accessed

Section