APPLICATION FOR ACCESS TO HEALTH RECORDS
(Data Protection Act 1998 & Access to Health Records Act 1990)
SECTION ONE - Details of record to be accessed
PATIENT:
Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Forename(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title (Mr./ Mrs./ Miss/ Ms./ Dr./ Other) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of birth . . . . . . . . . . . . . . . . . . . . .
RECORDS:
Name of hospital/ clinic/ surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approximate date of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nature of illness/ accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of consultant, doctor or other health professional providing treatment (if known)
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I would like *copies of the casenotes / to view the original casenotes (delete as required)
* All copies will be supplied on a C.D unless otherwise specified.
SECTION TWO – Application by someone other than the patient
(Please complete this section if you are not the patient identified in Section One. Please also
check in Section Three to see if you need to provide any documentary evidence).
Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Forename(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Title . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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SECTION THREE - Declaration 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
Data Protection Act 1998 or the Access to Health Records Act 1990.
Please indicate in which capacity you are making this application: o I am the patient. o I have been requested by the patient to make this application and I enclose the patient’s written authorisation. o I hold an enduring power of attorney over the affairs of this patient and I enclose a copy of the authority. o I am acting in loco parentis . The patient is under the age of 16 and is either incapable of understanding this request or has consented to my application. o I am the deceased patient’s personal representative. (Please indicate your relationship to the deceased patient, e.g. spouse, parent, child, legal executor. Please provide legal proof, e.g. copy of will, certificate of probate, official letter from a solicitor).
I am applying in my capacity as the deceased patient’s . . . . . . . . . . . . . . .
. . . . . . . and I enclose . . . . . . . . . . . . . . . . . . . . . . . . . . in support of my application. o I have a claim arising from the patient’s death and wish to access information relevant to that claim on the following grounds :
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Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . .