Application for access to medical records (Subject Access Request)

Details of the record to be accessed:

Patient first name(s): *

Patient surname: *

Details of the Person who wishes to access the records:

Are the details of the person who wishes to access the records different to the above? *

Yes

No

First name(s):

Surname:

Relationship to patient:

Your Email address: *

Your Telephone number:

Your Address:

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 Data Protection Act 2018.

Tick whichever of the following statements apply:

I am the patient

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

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

I am the deceased patient’s Personal Representative and attach confirmation of my appointment

I have a claim arising from the patient’s death and wish to access information relevant to my claim

Please specify:

The patient is incapable of understanding the request

The patient has consented to me making this request

Please specify your reasons:

Signature: *

Date:

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Application for access to medical records (Subject Access Request)

Details of the record to be accessed:

Details of the Person who wishes to access the records:

Declaration: