Subject access request

Address:

NHS Number:

Applicant Details (If different from the above)

Full Name

Organisation:

Telephone Number:

Mobile Number:

Address:

Request For

Please choose one option: *

Online Access (Recommended option)

Emailed Record (Recommended)

Printed Record (Not recommended)

Record Requested: *

My full record – see below

My record for these specific dates

My record for these specific conditions

My record for these specific events

Please specify specific dates:

Please specify specific conditions:

Please specify specific events:

If you are requesting full records, please note that prior to 2001 your records will display a summary of key information. If you require the full record prior to this date, please provide your reasons below:

Can we refuse to comply with a request?

We can refuse to comply with a subject access request if it is manifestly unfounded or excessive, taking into account whether the request is repetitive in nature. If we consider that a request is manifestly unfounded or excessive we can:

request a “reasonable fee” to deal with the request; or
refuse to deal with the request.

In either circumstance we will justify our decision. If we decide to charge a fee we will contact you promptly and inform you of the likely costs. We do not need to comply with the request until the fee is received.

How long do we have to comply?

We will act on the subject access request without undue delay and at the latest within one month of receipt. We will calculate the time limit from the day after we receive the request (whether the day after is a working day or not) until the corresponding calendar date in the next month.

Can we extend the time for a response?

We can extend the time to respond by a further two months if the request is complex or we have received a number of requests from the patient. We will let you know within one month of receiving your request and explain why the extension is necessary.

Decleration

I am the patient

I have been asked to act by the patient and attach the patient’s written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18 and has consented to my making this request

I have full parental responsibility for the patient and the patient is under the age of 18 and is incapable of understanding the request

I 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 the deceased person’s Personal Representative and attach confirmation of my appointment (Grant of Probate/Letters of Administration)

I have written, and witnessed, consent from the deceased person’s Personal Representative and attach Proof of Appointment

I have a claim arising from the person’s death (Please state details below)

Proof of Identity Provided

Please specify item of ID: *

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.

Signature: *

Name: *

Date: *

Please Attach Your Files Here:

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