Subject Access Request Form

You will appreciate that health data relating to any individual is highly confidential and the Practice must ensure that it releases such data only to the person to whom it relates, or to a person authorised to act on his or her behalf. If you require to see any health data, please complete this online Request Form as fully and accurately as possible to enable us to locate the exact information you require.

The General Data Protection Regulations (GDPR) gives you the statutory right of access to any information, manual (paper) or computerised.  You may wish to authorise someone else to make your application on your behalf and if you have parental responsibilities you may make an application to see your child’s notes, if they are under the age of twelve years.

You do not have to give a reason for applying for access to your General Practice records. If you do not need access to your entire records, it would be helpful if you would inform us of the periods and area of your health records that you require, along with details which you feel may have relevance (e.g. clinic type, location, dates).

The Practice will deal with your request as quickly as possible.

If you request copies of all or part of your medical record, these will be ready within the allocated timescales specified by the Regulations (which is currently 28 days from receipt of your accurately completed form and confirmation of consent), and we will telephone you when they are available for you to come to the Practice to collect them.

Under certain circumstances, this period can be extended to 3 months but we will keep you informed of the progress of your request during this extended period.
We will not make a charge for the first request for access to your medical records. 

We may, however, charge for subsequent requests or if we deem that the volume of information requested is excessive. 

You have the right to simply view your records (i.e. not receive a copy in a permanent form); information on how to arrange this is detailed below.
If you request to see the original records, you will be invited to make an appointment at a mutually convenient time to view them. 

If you request copies, these will be ready within the allocated timescales specified by the Regulations, and we will telephone you when they are available for you to come to the Practice to collect them. 

Two forms of identity must be provided (one of which must be photographic). This is to ensure information is not released to unauthorised individuals. The table below outlines the proof of identity we can accept.

TYPE OF APPLICATIONIDENTIFICATION REQUIRED
Patient applying for their own 
Can be waived if the applicant is known to the Staff Member accepting the request		One which must be 
photographic i.e. 
passport. One containing individuals 
name and address
Third Party Applying. Consent of Patient will be 
required  BEFORE the request will be 
processed		One containing Third Party name and 
address One must be Photographic ID 
of Third Party  
Applying on behalf of a child 

We will ALWAYS obtain consent for release of 
records from a child age 12+ to <16 if a third party is making request		One which must be Child’s 
birth certificate Photographic ID of person with parental rights

If you are completing this application on behalf of another person, the Practice will require their authorisation before we can release the data to you. The person whose information is being requested should sign the relevant section within the online form.

If the patient is a child (i.e. under 16 years of age) the application may be made by someone with parental responsibilities – in most cases this means a parent or guardian.

If the child is capable of understanding the nature of the application, his or her consent should be obtained or, alternatively, the child may submit an application on their own behalf.  

Children will, generally, be presumed to understand the nature of the application if aged between 13 and 16 however, all cases will be considered individually.

Section 1 : Patient Details

Name
Former Name
Date of Birth
Address
If you are applying to view your own records, please go to Section 2.

If you are applying to view another person’s record, please go to Section 3.

Section 2 : Record Requested

Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)
Please specify what information you are requesting:

Section 3 : Details and Declaration of Applicant

Please complete if you are requesting access on behalf of the above-named patient.

If more than one person is to be given access then please list the above details for each additional person on a separate sheet of paper
Name
Address
Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)
Please specify what information you are requesting:
Reason for access:
Declaration
I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records

Section 4 : Proof of Identity

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records.

Section 5 : Consent for Children

If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself.

They may wish a parent to countersign as well.

Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well.

If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below.
I am the parent/guardian/person with parental responsibility
Address
You will be telephoned when the copies are ready for collection or posting.

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