Application form for access to medical records

The Data Protection Act 1998 gives you the statutory right of access to any health record manual (paper) or computerized. You may wish to authorize someone else to make your application on your behalf. In certain circumstances your records or part of your records may be withheld. If this is the case this will be discussed with you.

FEES PAYABLE

First request free of charge, provision of duplicate records chargeable

TIMESCALE

The Practice will deal with your request promptly and in any event the records will be available within 28 days of receipt of your accurately completed form and your fee where applicable.

SUBMISSION OF FORM

Please return this form to Reception for the attention of the Lead of Reports

REQUEST FOR ACCESS TO MEDICAL RECORDS

You are 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
Access to health records is an important matter. The release of certain data may in certain
Circumstances cause distress. You may wish to consult an appropriate health professional before completing your application.

SECTION 1: PATIENT REQUEST TO ACCESS MEDICAL RECORDS

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 record referred to below under the terms of the Data Protection Act 2018.

Surname:
Forename(s):
Address:
Post Code:
Date of Birth:
Telephone No.:-

Reason for the request:

Signed:

Date: