Subject Access Request I am… the patient (data subject) the parent/guardian of a data subject under 16 years old appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order acting on behalf of the data subject who is unable to complete this form Full NamePlease included any former namesDate of Birth DD slash MM slash YYYY Email Please double check you’ve entered the correct email addressPhoneNHS Number if known OptionalCurrent postal addresspostcode OptionalAdditional InformationUnder the Data Protection Act you do not have to provide a reason for applying for access to health records. However to help us save time and resources, it would be helpful if you could provide details informing us of periods and parts of the health records you require access to, along with details which you may feel are relevant: OptionalDate from Optional DD slash MM slash YYYY Date to Optional DD slash MM slash YYYY Specific illness or problems : Optionale.g. radiology results, information relating to a specific accidentDeclaration I confirm that as the applicant I am over 16 years oldIf there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case. Under the terms of the Data Protection Act, Subject Access Requests will be responded to within one calendar month after receiving all necessary information and/or fee required to process the request. Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed. Please note that we will contact the patient by telephone (using the information on their records) to verify the patients request and identityI declare that information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act: *SignatureReset to re-sign.Privacy Consent I consent to the practice collecting and storing my data from this form.This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.Phone OptionalThis field is for validation purposes and should be left unchanged.
