Subject Access Request Form - Access to Medical Records

Personal information collected from you by this form, is required to enable your request to be processed, this personal information will only be used in connection with the processing of this Subject Access Request. By completing this form, you are making a request under the General Data Protection Regulation (GDPR) for information held about you by the practice that you are eligible to receive. All requests are subject to approval by the GP.

PLEASE ALLOW UP TO 1 MONTH FOR COMPLETION

Patients Details

Patients Name

First Last

Patients Date of Birth

Contact Number

Telephone

Request Details

Please confirm the level of access to your medical records you require (please tick ONE box only):

Online Access (via NHS App) – records from 1st April 2017 (these requests will be dealt with by the Health Centre admin team)

Specific Records – please specify exactly which records you need in the box below (these requests will be dealt with by an NHS outsourcing service, Medi2Data will provide access to your online medical records through a secure ‘https://’ url link)

Full records from birth (these requests will be dealt with by an NHS outsourcing service, Medi2Data will provide access to your online medical records through a secure ‘https://’ url link, paper notes will be requested and copied for you to collect)

Specific records required, dates, medical conditions or documents required:

Proof of Identity

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 2.

Please submit: 1. Proof of ID, 2. A utility bill dated within 3 months. We cannot process the request without both documents being uploaded.

By signing below, you indicate that you are the individual named above. The practice cannot accept requests regarding your personal data from anyone else, including family members. We may need to contact you for further identifying information before responding to your request.

Signature

Please PRINT your full name

Charges Payable: In accordance with legislation no fee will be charged for your request, unless the request is manifestly unfounded or excessive, particularly if it is repetitive. Before any further action is taken, we will contact you with details of our “reasonable administrative charges” in order to comply with your request.