We respects the rights of individuals to have copies of their information wherever possible.
Personal information collected from you by this form, is required to enable your request to be processed, this personal information will only be used in connection with the processing of this Subject Access Request.
Charges Payable In accordance with legislation no fee will be charged for your request, unless the request is manifestly unfounded or excessive, particularly if it is repetitive. Before any further action is taken, we will contact you with details of our “reasonable administrative charges” in order to comply with your request.
Please complete the form below.
1. Details of Patient/Clients/Staff members records to be accessed (Please complete one form per person)
Surname
Forename (s)
Any former names (If applicable)
Date of Birth
Current Address
Full Postcode
NHS Number (if known)
Previous Address & Postcode (if applicable)
If further details are available please detail below
2. Details of Records to be Accessed or Released
Details
Details
Details
Other (please specify)
3. If option 2 does not apply please complete: Details of Records to be Accessed
In order to locate the records you require please provide as much information as possible. Please list the department or services you have accessed that you require records from: i.e. PALs, complaints, continuing healthcare or human resources etc
Department or services accessed. Please give details of dates from & to
Department or services accessed. Please give details of dates from & to
Department or services accessed. Please give details of dates from & to
4. Details of applicant (Complete if different to patients/clients/staff members details)
Full Name
Company (if applicable)
Relationship with individual who’s records have been requested
Address to which a reply should be sent
Postcode
Telephone Number
5. Authorisation to release to applicant (to be completed by the patients/clients/staff member if not making their own request)
Full Name
Date
Declaration
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.
Please select one box below:
Please upload relevant documentation as requested above (if applicable)
Please Note
If you are making an application on the behalf of somebody else, we require evidence of your authority to do so i.e., personal authority, court order etc.
It may be necessary to provide evidence of identity (i.e., Driving Licence).
If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
Under the terms of the Data Protection Act, Subject Access Requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
If you are making a request under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client’s record 40 days immediately preceding the date of this request, otherwise requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.
Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.
Full Name
Date
