Subject Access Request Form

Access to Health Records under the General Data Protection Regulations 2016 (Subject Access Request)

Patient’s authority consent form for release of health records (Manual or Computerised Health Records)

Medical records will be emailed to the email address provided.

(* = required field)

Identity of individual about whom information is requested

Full Name *

Former name(s)

Current address *

Former address (with date of change)

Date of birth *

NHS number (if known)

Phone Number *

Email address *

What is being applied for? (tick as applicable) *

I am applying for access to view my health records

I am applying for copies of my health record

You do not have to give a reason for applying for access to your health records. However, to help the Practice save time and resources, it would be helpful if you could provide details below, informing us of periods and elements of your health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports etc. Please use the space below to document this information:

Dates and types of records *

Signature of applicant *

Please tick the appropriate box identifying whether you or a representative on your behalf is applying for access. *

I am applying to access my health records

I have instructed my authorised representative to apply on my behalf

If you are the patient’s representative please give details here:

Name and address of representative

Phone Number

Email Address

Signature of representative

Message

Identity of individual about whom information is requested

If you are the patient’s representative please give details here:

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