Subject Access Request

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All questions marked with a * are mandatory

I am: *

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Applicant's Details

Patient's Details

Please included any former names

Please double check you've entered the correct email address

Help Us To Help You

Providing a NHS Number means that we can find a patient record more accurately, saving time and resources.

If known

Would there have been a former postal address we would have on record?: *

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Additional Information

Under 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

e.g. radiology results, information relating to a specific accident

Proof of Authority

If you are making an application on the behalf of somebody else we require evidence of your authority

Please upload a copy of your evidence

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Details of where medical records are to be sent

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Declaration

You are requesting access to the records for

Please return to the previous pages to make any amendments

If 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 identity

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This form collects personal and medical information about you and 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.

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