Application for access to medical records (SAR)

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

Patient’s Details

Surname:

First Name:

Previous Surnames:

Title:

Date of Birth:

Please use this date format: DD/MM/YYYY

NHS number (if known):

Address including postcode:

Telephone number:

Email Address:

Any responses we send will go to this email address.

Hospital number (if known):

What is the age of the patient?

Under 13

13-15

16-17

18 or over

Whose records are you requesting?

I am requesting access to my own medical records

I am requesting access to another person’s medical records

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)

What type of access you are requesting?

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

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/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

Please enter the date range you require:

Please describe the condition or incident you are requesting records for:

Details and Declaration of Applicant

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

Surname:

First Name:

Title:

Address including postcode:

Telephone number:

Relationship to patient:

What type of access you are requesting?

I am applying for access to view the records only

I am applying for an electronic copy of the medical record

I am applying for a printed copy of the medical record

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/incident only

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

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

Please enter the date range you require:

Please describe the condition or incident you are requesting records for:

Reason for access:

I have been authorised to act by the patient

I have full parental responsibility for a patient under the age of 18 and they have consented to this request

I have full parental responsibility for a patient under the age of 18 and they are unable to understand the request

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

I am acting in loco parentis and the patient is unable to understand the request

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

I have written, witnessed consent from the deceased person’s personal representative and will attach proof of appointment

I have a claim arising from the person’s death

Declaration

By submitting this request, you confirm that the information you have provided is accurate to the best of your knowledge, and that you are legally entitled to request access to the health records under the UK Data Protection Act 2018.

Confirmation

I confirm that I have read and agree to the declaration above

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.

Does the patient have sufficient understanding to provide their own consent?

Yes, the patient can sign for themselves

No, a parent/guardian will provide consent

Does the patient want a parent/guardian to countersign?

No, I will sign myself

Yes, I would like a parent/guardian to additionally countersign

Applicant signature:

Date:

On behalf of:

Confirmation

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

Patient signature:

Date:

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.

Your photo ID needs to have a clear picture of you holding the ID next to your face. Alternatively, you can come into the practice and show us in person.

Upload a photograph or document

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Patient’s Details

Record requested

Details and Declaration of Applicant

Declaration

Proof of identity