Medical report request If you would like to request a medical report, please use this form. Application for access to medical records (SAR) In accordance with the UK General Data Protection Regulation (UK GDPR) Section 1: Patient details Title Surname Forename Former name (if applicable) Date of birth Telephone number Address Postcode NHS number (if known) Hospital number (if known) If you are applying to view your own records, please go to Section 2. If you are applying to view another person’s record, please go to Section 3. Section 2: Record requested Please tick the relevant boxes below. 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) 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 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 Patient signature Write your full name to sign this application Date of signing the application Section 3: Details and Declaration of Applicant Please complete if you are requesting access on behalf of the above-named patient Title Surname Forename(s) Address Postcode Telephone number Relationship to Patient If more than one person is to be given access then please list the above details for each additional person below Choose a relevant option I am applying for access to view the records only I am applying for an electronic copy of the medical record I am applying for a printed copy of the medical record 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 the electronic records (held on computer) I would like a copy of all the electronic and paper records since birth Reason 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 either 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) Declaration 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. Applicant signature Write the full name of the applicant to sign the declaration Date of the declaration I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records Patient signature For patients: write your full name to confirm that you give permission for the organisation to communicate with the person identified above regarding your medical records Date Section 4: Proof of identity Under 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. Section 5: Consent for children If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand 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. If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below. Tick the box to give consent if you are the patient aged 13 – 18 years I am the patient aged 13 – 18 years For the parent/guardian/person with parental responsibility: complete the fields below Your signature Write your full name to sign the document Full name Address Date 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) Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form. Identification verification must be verified through 2 forms of ID One of which must contain a photo e.g., passport, photo driving licence or bank statement. Where this is not available, vouching by a member of staff or by confirmation of information in the records by one of the clinicians may be used. If this is a proxy request, where patient has capacity, both patient and proxy should provide identification as above in person. Request received Reviewed by Request completed Request refused Fee (see section 6.4) Date sent Comments Patient identity verified by Date it was verified Method Photo ID or proof of residence – Type details below Vouching – by whom (provide details below) Vouching with information in record – by whom (provide details below) Proxy identity verified by Date it was verified Method Photo ID or proof of residence – Type details below Vouching – by whom (provide details below) Vouching with information in record – by whom (provide details below)