Access to Records

In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records.

Such requests should be made by completing this form or you can complete the online form below. No information will be released until the practice is satisfied with the identity of the requestor, and without the patient consent unless we are legally obliged to do so.

Please note that Subject Access Requests (SARs) can take up to one month to process, starting from the date we have received all required information and have verified the identity of the requesting individual. Delays may occur if any necessary details are missing, so we encourage you to provide all requested information promptly to avoid any processing delays.

It is the patient’s responsibility to provide appropriate identification. The timescale for responding to a SAR does not begin until the practice has received the requested information, and is satisfied with your identity as the requestor.

"*" indicates required fields

Patient Details

Forename*

Surname*

Date of Birth*

DD slash MM slash YYYY

NHS Number (if known)

Address*

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Telephone*

Email Address

Record Requested

The more specific you can be, the easier it is for us to quickly provide you with the records requested.

Record Requested*

Please provide me with a copy of all records held

Please provide me with a copy of records between the dates specified

Please provide me with a copy of records relating to the incident specified

Please provide me with a copy of records relating to the condition specified

Date from*

DD slash MM slash YYYY

Date to*

DD slash MM slash YYYY

Incident*

Condition*

Details and declaration of applicant

Please enter details of applicant if different from Section 1

Forename

Surname

Address

Postcode

Telephone

Declaration*

I am the patient

I have been asked to act by the patient and attach the patients written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18 and a) has consent to my making this request or b) is incapable of understanding the request

I have been appointed by the court to manage the patient's affairs and attach a certified copy of the court order appointing me to do so

I am acting in loco parentis and the patient is incapable of understanding the request

I am the deceased person's Personal Representative and attach confirmation of my appointment (Grant of Probate/Letters of Administration)

I have written, and witnessed, consent from the deceased person's Personal Representative and attach Proof of Appointment

I have a claim arising from the person's death (Please state details below and attach documentary evidence) (Please provide evidence of the relationship to the deceased)

Required*

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 and the Access to Health Records Act 1990.

Proof of Identity

Evidence of the patient's and/or the patient representative's identity will be required. Please attach copy 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 own records	One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card etc.
B	Someone applying on behalf of an individual (Representative)	One item showing proof of the patient's identity and one item showing proof of the representative's identity (see examples in A above)
C	Person with parental responsibility applying on behalf of a child	Copy of birth certificate of child & copy of correspondance addressed to person with parental responsibility relating to the patient
D	Power of Attorney/Agent applying on behalf of an individual	Copy of a court order authorising Power of Attorney/Agent plus proof of the patient's identity (see examples in A above)

Upload evidence*

Drop files here or Select files

Max. file size: 128 MB.

Please use the box below to provide any other relevant information that may help us to locate the information you require.

Signature*

Phone

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