Application for Access to Medical Records (SAR) In accordance with the UK General Data Protection Regulation (UK GDPR). Patient DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date Day Month Year Contact NumberAddress Street Address Address Line 2 City Postcode NHS number (if known) Optional Hospital number (if known) Optional Are you applying to view your own records or to view another person’s record? Applying to view my own records Applying to view another person’s record Record requestedPlease tick the relevant boxes below. I am applying for access to view my records only I am applying for an electronic copy of my medical record I am applying for a printed copy of my medical record The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)Please specify what information you are requesting: I would like a copy of records between specific dates only (please give dates below) I would like a copy of records relating to a specific condition/specific incident only (please detail below) I would like a copy of all my electronic records (held on computer) I would like a copy of all my electronic and paper records since birth Further DetailsDetails and Declaration of ApplicantPlease complete if you are requesting access on behalf of the above-named patient.Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Contact numberAddress Street Address Address Line 2 City Postcode Relationship to Patient (If more than one person is to be given access then please list the above details for each additional person on a separate sheet of paper)Please tick the relevant boxes below. I am applying for access to view my records only I am applying for an electronic copy of my medical record I am applying for a printed copy of my medical record The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)Please specify what information you are requesting: I would like a copy of records between specific dates only (please give dates below) I would like a copy of records relating to a specific condition/specific incident only (please detail below) I would like a copy of all my electronic records (held on computer) I would like a copy of all my electronic and paper records since birth Further DetailsReason for access: I have been asked to act by the patient 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 acting in loco parentis and the patient is incapable of understanding the request 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) Further DetailsDeclaration 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 UK Data Protection Act 2018. You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.Consent I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records.Proof of identityUnder the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records. Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this. Consent for childrenunderstand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself. They may wish a parent to countersign as well. Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well. Additional InformationYou will be telephoned when the copies are ready for collection or posting. Before returning this form, please ensure that you: • Have signed and dated the form • Are able to provide proof of your identity or alternatively confirmed your identity by a countersignature • Enclosed documentation to support your request (if applicable)