Application for Access to GP Medical Records (Access to Health Records Act 1990 / Data Protection Act 1998)

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1 (Preston Office) 3 Caxton Road, Fulwood, Preston, PR2 9ZZ (Access to Health Records Act 1990 / Data Protection Act 1998) Under the Data Protection Act 1998 you are entitled to apply for access to your GP Medical Record. In addition, The Access To Health Records Act 1990 entitles you to access the GP Medical Record of a deceased person where you have a legitimate reason to do so. To enable your application to be processed quickly and efficiently you should complete this form: i) If the request is to access your own GP Medical Record you should complete Sections A, C and D; ii) If you are requesting access to the GP Medical Record of another person you must also complete Section B. Do not complete Section E as this is for office use only. Fees Under the Data Protection Act 1998 (Fees and Miscellaneous Provisions) Regulations 2001 a fee can be charged for viewing and/or providing copies of health records, which does not result in a profit for the record holder. A charge of 35 is made for a copy of the GP Medical Record to be sent to you. This cost includes copying and postage via Royal Mail Special Delivery. Send the completed form and other documentation to the address above. Your Checklist: Completed form with your signature Documents to back up your entitlement to the GP Medical Record (Section B) Your Identity Validation documents (Section C) Cheque (where applicable) Should you have any query regarding completion of this form you should contact: Tel: Fax: AHR1/07/13

2 SECTION A Details of the person whose GP Medical Record you wish to access Surname (including former name(s) if relevant): Forename (s): Title (Mr/Mrs/Miss/Ms/other): Address: Postcode: Former address/es (if applicable): Date of Birth: / / NHS Number (if known): Name / Address of GP (family doctor): Postcode: Please use the space below to detail any specific parts of the GP Medical Record required. Do include dates, location, name of the health professionals involved and parts of the record you require i.e. written diagnosis and reports. Covering the time period (approximately) between / / and / /. Tick one of the boxes below as appropriate: I am applying for access to view the GP Medical Record I am applying for copies of the GP Medical Record If you are applying for access to your own GP Medical Record, go to Section C. If you are applying for access to the GP Medical Record of another person continue and complete Section B. 2 AHR1/07/13

3 SECTION B Your details Surname: Forename(s): Title: Address: Postcode: Your relationship to the person named in Section A: e.g. Husband / Wife / Father / Mother / Brother / Sister / Partner / Solicitor / other (please specify). In what capacity are you applying for access to the GP Medical Record of another person? Please tick one of the following as appropriate: I have been asked to act by the person named in Section A: Signed authorisation is given below in Section D (delete as appropriate) yes/no Written authorisation is attached (delete as appropriate) yes/no I am acting in loco parentis for the child named in Section A who is under 16 years of age. I am the personal representative of the person named in Section A and attach confirmation of my appointment (i.e. Letters of Administration, Grant of Probate, Certified copy of Will, Lasting Power of Attorney). Note: If this application relates to the GP Medical Record of a person who is deceased you must complete the box below to provide a reason for your access request. Reason for Request: I have a claim arising from the death of the person named in Section A and wish to access information relevant to my claim on the following grounds (please describe in the space below): 3 AHR1/07/13

4 SECTION C Your Identity Verification To ensure confidentiality of GP Medical Records it is necessary for applicants to provide proof of identity. Two documents are required for this purpose, one which confirms your name and the other that confirms your address. Tick one box in list A and one in list B and send photocopies of these documents with your application. List A: List B: Full UK or European Community (EC) driving licence - either paper or photocard. (If a photocard the paper counterpart must also be presented); Valid Passport; Signed ID card with your photograph provided by your employer, or Armed Forces ID card: Front cover and inside page of your Pension Allowance Book; Front cover and inside page of your book for any other allowance or benefit; or Letter of entitlement to a benefit. Recent gas, electricity or telephone bill; Recent Bank or Credit card statement; Council Tax statement; Medical Card; or Inland Revenue Notice of Tax Code. 4 AHR1/07/13

5 SECTION D Fee Payable and Declaration I have included the fee of to obtain a copy of the medical record. (Cheques should be made payable to NHS Commissioning Board) 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 GP Medical Record referred to in Section A under the terms of the Access to Health Records Act 1990 or Data Protection Act I understand that under the Data Protection Act 1998 (Fees and Miscellaneous Provisions) Regulations 2001, there may be a charge for me to view or to be provided with a copy of the GP Medical Record requested. Due to the sensitive nature of the information being sent, the Primary Care Support Services (Preston Office) will only provide a copy of the GP Medical Record by secure postal service requiring a signature from the recipient when receiving or collecting the package. Signature: Date: / / Contact Telephone Number: If you have been asked to make this application by the person to whom the GP Medical Record relates, you should ask them to complete this section to authorise the Medical Record to be released to you. I certify that I am (print name): of (address): Postcode: and that (print person named in Section B) is applying on my behalf. Signed Date / / 5 AHR1/07/13

6 SECTION E For Primary Care Support Services (Preston Office) Use Only Fee: * received/*not appropriate (*delete as appropriate) Signed: Date: / / Print Name: Health Professional Advising: Access Provided on: / / Further action Corrections Requested Yes No Applicant Notified Outcome Yes No Copies Provided Yes No Copying Fee ( ) Yes No Comments: 6 AHR1/07/13

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