Application for Access to Health Records

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Application for Access to Health Records

Application for Access to Health Records

Section 1 - Patient Details

Title: *
Please use date format DD/MM/YYYY
Please include postcode.

Section 2 - Record Request

Please tick the relevant boxes that apply.
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Section 3 - Details and Declaration of Applicant

Please enter details of applicant if different from Section 1.
Title:

Declaration

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the GDPR.

Please Select: *

Section 4 - Proof of Identity

Please indicate how proof of ID will be confirmed: *

Section 4a

Evidence of the patient's and /or the patient's representative identity will be required.

Please attach copies of the required documentation to this application form. Examples of required documentation are:

 
  Type of Applicant Type of Documentation
A An individual applying for his/her records. One copy of identity required, e.g. copy of birth certificate, passport, driving liscence, plus one copy of a utility bill or medical card.
B Someone applying on behalf of an indivdual. One item showing proof of the patient's identity and one item showing proof of the representatives identity (see examples in 'A' above).

C

Person with parental responsibility applying on behalf of a child. Copy of birth certificate & copy of correspence addressed to person with parental responsibility, relating to the patient. 
D Power of Attorney/Agent applying on behalf of an individual.  Copy of court order authorising Power of Attorney/Agent plus proof of the patient's identity (see exampled in 'A' above).

Section 4b

This section is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if 4A cannot be fulfilled.

e.g. employee, client, patient, relative etc.

and that I have witnessed the signing of the above declaration. I am happy to be contacted if further information is required to support the identity of the applicant as required.

Please include postcode.

Additional Notes:

Before returning this form, please ensure that you have:

  • signed and dated this form
  • can provide proof of your identity or alternatively confirmed your identity by a countersignature
  • can provide documentation and consent to support your request (if applying for another person's records)

Incomplete applications will be returned; therefore please ensure you have the correct documentation before returning the form.