Access to Medical Records form

If you would like access to Medical records please complete this form.

Access to Medical Records Form

Access to Medical Records Form

Section 1: Patient Details

Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY.
Please include postcode

Section 2: Record Requested

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)

Section 3: Details and declaration of applicant

Please enter details of applicant id different from Section 1
Any responses we send will go to this email address.
Please include postcode

Declaration

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 GDPR.
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.

Section 4: Proof of identity

Section 4A: Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required.
You will be required to provide copies of the require documentation to this application form, these will need to be brought into the practice.
Examples of required documentation are:

  Type of applicant Type of documentation
A An individual applying for his/her

own records

One copy of identity required,

e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc.

B Someone applying on behalf of an

individual (Representative)

 

One item showing proof of the patient’s identity and one item showing proof of the

representative’s identity (see examples in ‘A’ above)

C Person with parental responsibility

applying on behalf of a child

Copy of birth certificate of child & copy of correspondence addressed to person with parental responsibility relating to the patient
D Power of Attorney/Agent applying on behalf of an individual Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)

Section 4B: Contersignature

This section is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if 4A cannot be fulfilled.
Insert what capacity, e.g. employee, client, patient, relative, etc.
please include postcode