Third party consent to allow access to medical records

Your Details (Patient Allowing Third Party Access)

Your First Name: *

Your Last Name: *

NHS Number (if known):

Address:

Mobile Phone Number:

Home Phone Number:

Your Representatives Details

First Name: *

Last Name: *

Relationship to You: *

Email Address: *

Address: *

Mobile Number: *

Alternative Number: *

Please tick which of the following applies (or all if necessary):

Next of Kin

Emergency Contact

Consent to Discuss Medical Records

Do you need to add the details of any other representatives?

Yes

No

Your Second Representatives Details

First Name: *

Last Name: *

Relationship to You: *

Email Address: *

Address: *

Mobile Number: *

Alternative Number: *

Declaration

*

I consent to the release of confidential information from my medical record as stated in this form to the person(s) stated above.

*

I understand my representative’s information will be stored for future reference in the medical file the Hollies Medical Practice holds in relation to me.

*

I understand that I must check any correspondence sent to my email from The Hollies Medical Practice.

Electronic Signature: *

Date: *

Next Steps

You may receive a telephone call to confirm this access request from a member of our administrative staff; this is to ensure any requests are made with the knowledge of the individual.

Access can be denied by the surgery should a member of the clinical team feel this request has not been made with the patients best interests at heart, this can be revoked by the surgery at any point.

You may also revoke this consent to share information with third parties at any point. You do not need to inform your representative of this.