Subject access request

Are you completing this form for yourself or on behalf of someone else? *

Myself

Someone else

Patient Details

First Name: *

Last Name: *

Date of Birth: *

Please use the format DD/MM/YYYY.

Telephone Number: *

Email Address: *

Former Names:

NHS Number:

Current Address: *

Please include postcode.

Previous Address:

Please include postcode.

Details of Records to be Accessed

In order to locate the records you require please provide as much information as possible. Please list the department or services you have accessed that you require records from: i.e. PALs, complaints, continuing healthcare or Human resources etc.

Please list below, including dates from and to as well as the department or services accessed: *

Details of Applicant

Only complete this section if different to patients/clients/staff members details.

Full Name: *

Company:

Telephone Number: *

Relationship with individual who’s records have been requested: *

Address:

Please include postcode.

Signed: *

Date:

Declaration

I declare that information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act.

Please specify: *

I am the patient/client/staff member (data subject).

I have been asked to act on behalf of the data subject and they have completed section 4 -authorisation above.

I am acting on behalf of the data subject who is unable to complete the authorisation section above (Covering letter with further details supplied).

I am the parent/guardian of a data subject under 16 years old who has completed the authorisation section above. (Please include proof such as birth certificate)

I am the parent/guardian of a data subject under 16 years old who is unable to understand the request and who has consented to my making the request on their behalf.

I have been appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order (attached).

I am the deceased patient/client’s personal representative and attach confirmation of my appointment.

I have a claim arising from the patient/client’s death and wish to access information relevant to my claim (Covering letter with further details to be supplied).

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, 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.

Signed: *

Date:

Please attach any relevant documentation to this form.

Maximum upload size: 67.11MB

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Patient Details

Details of Records to be Accessed

Details of Applicant

Declaration