Access to Medical Records (SAR)

Guidance notes – please read before completing this form

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.

Who is accessing the medical records? *

Patient requiring access to their own medical records

Proxy access to health records

Parents requiring access to their child’s (age 13-17) records

Section 1: Patient Details

Please specify: *

Surname: *

Previous Surname:

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode: *

NHS number (if known):

Hospital number (if known):

Section 2: Record Requested

I wish to have access to the following online services:

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

I would like a copy of records relating to a specific condition/specific incident only

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 provide details of the specific condition/incident: *

Patient Signature: *

Date:

Is the patient aged 13-17 and wishes a parent/guardian to countersign? *

Yes

No

Signature of Parent/Guardian: *

Date:

Section 3: Details and Declaration of Applicant

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

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

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/We are applying for access to view the patients records only

I am/We are applying for an electronic copy of the patients medical record

I am/We are applying for a printed copy of the patients medical record

Please specify what information you are requesting:

I/We would like a copy of records between specific dates only

I/We would like a copy of records relating to a specific condition/specific incident only

I/We would like a copy of all of the patients electronic records (held on computer)

I/We would like a copy of all of the patients electronic and paper records since birth

Date from: *

Date to: *

Please provide details of the specific condition/incident: *

Reason for access:

I/We have been asked to act by the patient

I/We have full parental responsibility for the patient and the patient is under the age of 18

I/We have been appointed by the Court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so

I am/We are acting in loco parentis and the patient is incapable of understanding the request

I am/We are the deceased person’s personal representative and attach confirmation of my appointment (grant of probate/letters of administration)

I/We have written, and witnessed, consent from the deceased person’s personalrepresentative and attach Proof of Appointment

I/We have a claim arising from the person’s death

I/We have full parental responsibility for the patient and the patient is under the age of 18 and: *

Has consented to my making this request

Is incapable of understanding the request

Please provide details of the claim arising from the person's death: *

Declaration

I/We (the proxy) 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.

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.

Proxy Signature: *

Representative 1

Date:

Proxy Signature:

Representative 2

Date:

I (the patient) confirm that I give permission for the organisation to communicate with the person identified above in regard to my medical records.

Patient Signature:

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 own 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.

Supporting Documentation

If applicable, please attach any documentation to support your request:

Maximum upload size: 67.11MB

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Access to Medical Records (SAR)

Guidance notes – please read before completing this form

Section 1: Patient Details

Section 2: Record Requested

Section 3: Details and Declaration of Applicant

Declaration

Section 4: Proof of Identity

Supporting Documentation

Appropriate Quality Healthcare