Application for Access to Medical Records

Details of person who wishes to access the records

Surname: *

Forename(s): *

NHS Number (if known):

Telephone number:

Email Address: *

Address (include postcode):

Details of the Patient Record to be Accessed (if different from above)

Patient Surname:

Forename(s):

NHS Number (if known):

Address (include postcode):

Details of my Application

*

I would like a copy of the above patient's summary (no fee)

I would like a copy of all records (all documentation and computer records) (no fee)

I would like a copy of records between specific dates only (no fee)

I would like a copy of records relating to a specific condition/specific incident only (no fee)

Please give details: *

PLEASE NOTE: If the records are an excessive amount and repeated requests, an admin fee may be charged which is deemed reasonable by the practice. The practice will give you an indication of what this fee is prior to your request being fulfilled. Any fee is payable in cash directly to the practice. Please allow 21 days from the date we receive the request to completion. Under the Data Protection Act 1998 you do not have to give a reason for applying for access to your health records. Under the Access to Health Records Act you will need to give reasons for applying for access to a deceased person’s health records.You may be asked to provide photographic identification.

My Declaration

Please tick one of the following statements: *

I am the patient and I fully consent to this request

I have been asked to act by the patient and bring the patient’s written authorisation into the practice

I am the parent and the patient is under age twelve and is incapable of understanding the request/has consented to me making the request

I am acting in Loco Parentis and the patient is under age twelve, and is incapable of understanding the request/has consented to me making the request

The patient is deceased and I have documentation proving my entitlement to their records

If you are making the request on behalf of the patient

Please tick one of the following statements:

Requests made to access the records of living persons - 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 Data Protection Act 1998. The patient whose records and information I am accessing has given their written consent for me to access their records and personal information. They also give consent for their record to be accessed by Parkside Family Practice staff. I fully understand that once I remove these records from Parkside's premises I am responsible for them.

Requests made to access the records of deceased persons - 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. I have provided documentary evidence such as the Power of Attorney, or Executor of Will documentation to evidence the proof of entitlement. Together with my identification documentation to prove my ID. I give consent for the medical record to be accessed by Parkside Family Practice staff, and for copies to be supplied to myself as the deceased persons authorised representative, as prescribed by myself above. I full understand that once I remove these records from Parkside's premises I am responsible for them.

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Application for Access to Medical Records

Details of person who wishes to access the records

Details of the Patient Record to be Accessed (if different from above)

Details of my Application

My Declaration

If you are making the request on behalf of the patient

Hay Fever