SAR application Form

SAR Application

Application form for access to health records in accordance with the General Data Protection Regulation (GDPR) data Subject Access Request.

Patient Details

Surname

Forename 

Maiden Name

Title

Mr/Mrs/ Miss/ Ms/ Other

Date of Birth

 

Telephone Number 

 

Address

 

Postcode 

 

Email 

 

NHS Number (if known

 

 

Record Requested

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 provide me with a copy of records between the following dates:

Please provide me with a copy of records relating to the following condition:

Please provide me with a copy of records relating to the following incident:

Declaration

I declare that the information given by me is correct to the best of my knowledge and that Iam entitled to apply for access to the health records referred to above under the terms of the GDPR.

Please tick the situation that applies:

I am the patient

 

I have been asked to act by the patient and attach the patient’s written authorisation

 

I have full parental responsibility for the patient and the patient is under the age of 18 and has either 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

Signature 

Date:

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.

Details and declaration of applicant:

Forename 

Surname 

Telephone 

Title *

Mr/ Mrs/Miss/Ms/Other

Address

Postcode 

Evidence Required

Please select which kind of applicant you are:

An individual applying for his/her own records

Someone applying on behalf of an individual (representative)

Person with parental responsibility applying on behalf of a child

Power of attorney/Agent applying on behalf of an individual

Before submitting this form, please ensure that you are able to provide:

·  Proof of your identity

·  Documentation to support your request (if applying for another person’s records)

Incomplete applications will be returned; therefore please ensure you have completed the form correctly

Examples of Identity verification

·         passport (any current and valid passport, or expired less than 6 months ago)

·         photo driving licence (current and valid)

·         birth certificate

with

·         utility/council tax bills (dated within the last 3 months)

·         bank statements (dated within the last 3 months)

·         HC2 (healthcare expenses) certificate

·         rough sleepers’ identity badge

·         hostel or accommodation registration or mail forwarding letter

 

Print and Submit Form to Practice