Application Form For Access To Health Records - Subject Access Request
As part of the General Data Protection Regulations (GDPR), patients have a right to access their health records. You can have access to your records by one of the following methods:

•	Online Access – We advise this option as you can simply log-in online and view your up-to-date record at any time you wish and can share it with whoever you wish too. By having online access to your record, you can also take advantage of being able to request your repeat medication and booking appointments too.
•	Emailed Report – We can email your health record to you. This enables you to view your record and is also an eco-friendly and cost-effective method.
•	Printed Report – We can also print your health record for you. This is option however is not eco-friendly and you will be charged at 5p per copy plus an additional £10.00 administration fee which we will invoice and expect payment first before processing.

Please now complete this application form below.

Patient Details

Name	     	NHS Number 	      	
Address	     	Date of birth	      	
		Home Telephone	      	
		Mobile Telephone	      	
		Email Address	      	

Applicant Details (if different from above)
Name	     	Organisation	     	
Address	     	Telephone	     	
		Mobile Telephone	     	

Request For: (please choose one option)
  Emailed Record	Recommended. 	
  Printed Record	Not recommended (see above).	

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:		

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.

Declaration
	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, or
 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:
(A List)	(B List)	
	Birth Certificate   		Utility Bill    	
	Passport		Medical Card	
	Driving Licence    		Other:	

Signature of Applicant
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	     	
Print Name	     	
Date	     	

For office use only
Authorising Signature		
Print Name		
Date