Application for Access to Medical Records

To apply for access to your Medical Records please complete and submit this form.

Application for Access to Medical Records

Application for Access to Medical Records

Details of the Records to be Accessed:

Are you requesting access to your own medical record? *

Details of the Person who wishes to access the records, if different to above:

Tick which ever of the following statements apply

Details of my Application

Please Note:

- If you are making an application on behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order, statutory requirement etc.
- It may be necessary to provide evidence of identity.
- If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
- Under current Data Protection Legislation requests will be responded to within 30 days after receiving all necessary information to process the request.
- Under Data Protection legislation, Information disclosed under a Subject Access Request may have certain information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.
- In all cases your GP will be asked to authorise the release of your records, and may in certain circumstances retain information where it is deemed may harm the patient.
- We do not hold records for deceased patients these can be accessed via NHS England at the following
- There is no charge for providing your copy records; however we may make a charge for subsequent or repeated requests.

Under current Data Protection Legislation you do not have to give a reason for applying for access to your health records. However providing medical records is a time consuming exercise, for which we have limited resource available. To help us please use this space below to inform us of certain specific periods and parts of your health record you may require.

This may include specific dates, consultant name and location, and parts of the records you require e.g. written diagnosis and reports. Note: defining the specific records you need may allow us to provide a quicker response.

Please tick as appropriate: