Data Protection Act 1998
Subject Access Request Application – 1939
Register Application
This form is to be used if you wish to find out what information, if any, The NHS
Information Centre is holding or is processing that relates to you.
Please return your completed application form to:
Information Governance Department
The NHS Information Centre for Health and Social Care
1 Trevelyan Square
Boar Lane
Leeds
LS1 6AE
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Section 1:
About Yourself
Title:
Surname:
First Name:
Former Surname:
Date of Birth:
Sex (Male/Female):
NHS Number (if known)
Telephone Number (day):
Email Address:
Home Address:
Postcode:
If you would have been known to us by a different name or at a different address
during the period to which the information you are seeking relates, please state
the name(s) and address (es) below:
Name:
From (date):
To (date):
From (date):
To (date):
Address:
Postcode
Name:
Address:
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Postcode
Section 2:
Proof of Identity
To help establish your identity, you must submit a photocopy of one document
from each of the following categories with your application.
i.
Confirmation of name1
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ii.
Full driving licence
Passport
Birth certificate
Marriage certificate
NHS Information Centre identity badge
Confirmation of address
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Utility bill
Bank statement
Credit card statement
Benefit book
Pension book
I am providing the following types of identification, which are attached to this
document.
i.
Confirmation of name
ii.
Confirmation of address
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Where you have had a change of name we will require evidence of the name for which you are
seeking information e.g. a birth certificate will not be considered as evidence for searches on a
married name.
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Section 3:
Helping us to find the information
Please use to space below to provide further details that may help to locate the
information you are seeking, such as:
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Full name
Address as at 29th September 1939 (if known)
DOB
Registration number etc
Section 4:
Declaration
The information that I have supplied in this application is correct, and I am the
person to whom it relates. For Power of Attorney please ensure you attach
copies of relevant authority.
Signature:
Date:
Your Checklist
Is your contact information correct?
Have you enclosed acceptable identification?
Have you signed the form?
Have you completed all the sections?
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