Application for Access to Medical Records (SAR) In accordance with the UK General Data Protection Regulation (UK GDPR) Section 1 – Patient DetailsName First Last Previous Surname OptionalDate of birth Day Month Year NHS number (if known) OptionalAddress Street Address Address Line 2 City Postcode Telephone NumberEmail Please select… If you are applying to view your own records If you are applying to view another person’s record Section 2 – Record requestedPlease 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)Please select… I am applying for access to view my records only I am applying for an electronic 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 Please provide details…Section 3 – Details and Declaration of ApplicantPlease complete if you are requesting access on behalf of the above-named patientName First Last Address Street Address Address Line 2 City Postcode Telephone numberRelationship to patientPlease select… I am applying for access to view the records only I am applying for an electronic 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… 1- I have been asked to act by the patient 2- I have full parental responsibility for the patient and the patient is under the age of 18 and: 2b- Has consented to my making this request, or 2a- Is incapable of understanding the request 3- 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 4- I am acting in loco parentis and the patient is incapable of understanding the request 5- I am the deceased person’s personal representative and attach confirmation of my appointment (grant of probate/letters of administration) 6- I have written, and witnessed, consent from the deceased person’s personal representative and attach Proof of Appointment 7- I have a claim arising from the person’s death (please state details below) If selecting option 2, please also select option 2a or 2b.Please provide details OptionalDeclaration 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 – Full NamePatient Signature: I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical recordsProof 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 childrenIf 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. Patient aged 13 – 18 years : Signature – Full name OptionalI am the… Parent Optional Guardian Optional Person with parental responsibility Optional Signature – Full name OptionalAddress Street Address Optional Address Line 2 Optional City Optional Postcode Optional Please upload proof of ID Drop files here or Select files Max. file size: 1 GB.