Subject Access Request

Application For Access To Medical Records (SAR)

In accordance with the UK General Data Protection Regulation (UK GDPR)

Section 1: Patient details

Surname

Previous Surname

First Names

Title

Date of Birth

NHS number (if known)

Hospital number (if known)

Address

Postcode

City

Country

Address

Phone Number

Email Address

Who is this request for?

Myself ( View your own records)

Someone else ( view another persons records)

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)

I am applying for access to view my records only

I am applying for an electronic copy of my medical record

I am applying for a printed copy of my medical record

Please specify what information you are requesting:

I would like a copy of records between specific dates only (please give dates below)

I would like a copy of records relating to a specific condition/specific incident only (please detail below)

I would like a copy of all my electronic records (held on computer)

I would like a copy of all my electronic and paper records since birth

Date from:

Date to:

Please give details

Patient Signature

Clear

Date

Declaration

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

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 UK Data Protection Act 2018.

Applicant Signature

Clear

Date

Patient Declaration

I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records

Patient Signature

Clear

Date

Section 4: Proof of identity

Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records.

Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this.

File Upload

Maximum file size: 268.44MB

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 patient aged 13 – 18 years

Signature

Clear

I am the parent/guardian/person with parental responsibility (please select))

Parent

Guardian

Person with parental responsibility

Signature

Clear

Date

Full Name

Address

Address

Address

Address

Postcode
Postcode

City
City

Country
Country

Address

Contact Number

You will be telephoned when the copies are ready for collection or posting.

If you are human, leave this field blank.

Section 1: Patient details

Section 2: Record requested

Section 3: Details and Declaration of Applicant

Declaration

Section 4: Proof of identity

Section 5: Consent for children