Access to Health Records/Subject Access Request

The UK General Data Protection Regulation 2016 (UK GDPR) and Data Protection Act 2018 gives every living person, or an authorised representative, the right to apply for access to health records. Please contact us for alternative methods of obtaining access if you are unable to make a request in writing.

I am

the patient (data subject)

the parent/guardian of a data subject under 16 years old

appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order

the deceased patient/client’s personal representative.

making a claim arising from the patient/client’s death and wish to access information relevant to my claim

acting on behalf of the data subject who is unable to complete this form

Patient's Details

Name:

First Last

Please included any former names

Date of Birth:

Phone Number:

Email Address:

Please double check you’ve entered the correct email address

NHS Number if known: Optional

Current Address:

Street Address Address Line 2 City Postcode

Would there have been a former postal address we would have on record?:

Yes

Additional Information

Under the Data Protection Act you do not have to provide a reason for applying for access to health records. However to help us save time and resources, it would be helpful if you could provide details informing us of periods and parts of the health records you require access to, along with details which you may feel are relevant: Optional

Date from:

Date to:

Specific illness or problems:

e.g. radiology results, information relating to a specific accident

Signature

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: