Consent for proxy access to GP online services

Medical Information to be Accessed

Your First Name: *

Your Last Name: *

Your Mobile Number:

Your Full Address: *

Section 1 – Responsibility

I/We, the representatives, wish to have online access to the services ticked in section 3 for the patient of this form.

I/We understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:

I/We have read and understood the information leaflet provided by the Practice and agree that I/We will treat the patient information as confidential.

I/We will be responsible for the security of the information that I/We see or download.

I/We will contact the practice as soon as possible if I/We suspect that the account has been accessed by someone without my/our agreement.

If I/We see information in the record that is not about the patient, or is inaccurate, I/We will contact the practice as soon as possible. I/We will treat any information which is not about the patient as being strictly confidential.

Signature: *

Date: *

Section 2 – Granting Proxy Access

I, the patient give permission to my GP Practice ‘The Hollies Medical Practice’ to give the representatives stated on this form, proxy access to the online services as indicated below in section 3.

I reserve the right to reverse any decision I make in granting proxy access at any time.

I understand the risks of allowing someone else to have access to my health record

I have read and understood the information leaflet provided on the left hand side of this screen.

Signature: *

Date: *

Section 3 – Access Levels

Please grant the following access to my proxy:

Online appointment booking

Online prescription management

Accessing my medical records, to the level of access approved by the GP surgery

Signature: *

Date: *

Representative 1

This is for the people seeking proxy access to the patient’s online medical record, appointment or prescriptions.

Surname:

First Name:

Date of Birth:

Address including postcode:

Home Number:

Mobile Number:

Relationship to Patient:

You must already be signed up to online access to be granted proxy access, please confirm you already have an online access account:

I confirm I already have an online access account

Representative 2

This is for the people seeking proxy access to the patient’s online medical record, appointment or prescriptions.

Surname:

First Name:

Date of Birth:

Address including postcode:

Home Number:

Mobile Number:

Relationship to Patient:

You must already be signed up to online access to be granted proxy access, please confirm you already have an online access account:

I confirm I already have an online access account

Section 4 – Only For Patients Without Capacity

If the above named patient does not have capacity to grant access but it is deemed in their best interests for access to be granted proof of lack of capacity must be provided before access can be granted.

Please select which of the following applies:

Court ordered lack of capacity.

Court ordered under the mental health capacity act.

I, the representative am the patients full time carer.

I, the representative am the patients power of attorney.

I understand that as I, the representative have selected one of the above options I must provide proof of status within 21 working days for this request to be approved.

Section 5 – For Patients Aged 0-10

Parents can be granted proxy access for children between the ages of 0 to 10 years. Once the child turns 11 we are legally obliged to ask if your child consents to parents or guardians having access to their medical information. You will be contacted on the patients 11th birthday to inform you your access levels will be diminished to booking appointments and ordering prescriptions only, you are not able to see any further medical information without signed consent from the patient.

I understand that I/we the representatives will not have access to the patient’s records once they turn 11 years old. The patient must contact us on their 11th birthday to ensure access can continue.

Next Steps

The person you are granting proxy access to must now wait up to 14 working days for this request to be approved. Access is not granted immediately.

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 and to safeguard individuals.

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 access can be revoked by the surgery at any point.

Confirmation of this account being activated will be sent back via email, you must ensure you routinely check your emails for surgery correspondence.

Finally we ask that you confirm the following:

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

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Medical Information to be Accessed

Section 1 – Responsibility

Section 2 – Granting Proxy Access

Section 3 – Access Levels

Representative 1

Representative 2

Section 4 – Only For Patients Without Capacity

Section 5 – For Patients Aged 0-10

Next Steps