Access to Deceased Patient records Application Form

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Application for Access to Health Records relating to a deceased person
(under the subject access provisions of the Access to Health Records Act 1990)
The Leicestershire Partnership NHS Trust provides a wide range of patient services in a variety of settings such
as patients’ homes, daycare centre’s and hospitals. To help us deal with your request to access health records,
please complete as much of this application form as possible.
Section A – Information about the person whose health records are being requested.
Surname:
Forename(s)
Any other name(s) the person was known by
(For example: previous surnames, or names the
person preferred to be known as):
Date of Birth:
Date of Death:
Address at date of death (with postcode) :
Previous address(es) (with postcode) :
Approximate date of change of address(es):
NHS Number: (if known)
Any hospital numbers: (if known)
Please give any information about the health
records you wish to have access to,
including where the person received care
and approximate date(s):
Section B – Access requested
(please tick as appropriate)
I wish to view the records personally
I wish to receive copies of the records
Please Note: a fee may be payable
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Section C – to be completed by the person making the request
Please tick as appropriate
I am the patient’s personal representative and attach confirmation of my appointment
I have a claim arising out of the patient’s death and wish to access information relevant to my
claim and attach documentary evidence confirming this claim
I am the patient’s next of kin and attach confirmation of this
If none of the above, please explain your relationship to the patient and the reason for requesting access to their
records:
Relationship to the patient:
Reason for requesting access to their records:
Name of person making the request:
(proof of identity will be required before any records
can be released)
Address: (with postcode)
Day time telephone number:
Warning: Please be advised that the making of false or misleading statements in order to obtain access
to personal information to which you are not entitled is a criminal offence.
I declare that the information above is accurate to the best of my knowledge:
Signed: ……………………………………………………………………. Date: …………………………………….
Section D – Certification of the applicant
Name:
Address: (with postcode)
I have known the applicant for ….. years. The applicant is known to me under the above name as an employee /
client / patient / personal friend and I have witnessed the applicant sign this form.
Signed: …………………………………………………………………… Date: …………………………….
Please Note: Copy records cannot be released until full payment of any fee applicable under the Act has been
received.
Please send the completed application form and any supporting evidence to:
Subject Access Requests,
Information Requests Team,
Suite P1, Bridge Park Plaza
Bridge Park Road, Thurmaston
Leicester, LE4 8BL
Once we have received this completed application form, you will hear from us about your request for access to
health records within the next 40 days. All correspondence will be sent to the address of the applicant.
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