APPLICATION FOR ACCESS TO FULL ONLINE MEDICAL RECORD
Data Protection Act 2018 (GDPR) - Subject Access Request

Swarland Avenue Surgery

Under the UK General Data Protection Regulation, Data Protection Act 2018, you have the right to apply for access to your records and in some case, records of other people as an authorised representative. This is known as a Subject Access Request (SAR).

•	Your request must be made in writing to the practice 
•	No fees apply for this request 
•	We are required to respond to you within 30 days but in some circumstances, we may require longer to process your request 
•	You will need to provide adequate I.D for this request (for example driving license, passport or a formal document stating your identity).

Please complete the SUBJECT TO ACCESS REQUEST FORM 

To gain access to your full online health record, please complete the relevant section(s) of the SUBJECT ACCESS REQUEST FORM and provide this to the practice. All patients should have had access to all their data on their record from April 2020.

Your right to see certain information may be limited – for example, if this includes details about other individuals (third party) or any information that may cause harm. 

	

APPLICATION FOR ACCESS TO ONLINE MEDICAL RECORD
Data Protection Act 2018 (GDPR) - Subject Access Request

Section 1: Details of the Record to be Accessed
Patient Surname	NHS Number
	
Forename(s)	Address

	
Date of Birth		

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 Data Protection Act 2018.
Details of the Person who wishes to access the records, if different to above:
Surname		
Forename(s)		
Address	

	
Telephone Number		
Relationship to Patient		

Section 2: Record requested 

The more specific you can be, the easier it is for us to quickly provide you with the online records requested. For example, date range or records relating to a diagnosis / accident. However, under the Data Protection Act 2018 (GDPR) you do not have to give a reason for applying for access to your health records.

Please provide me access to my full online medical record  

	
Please provide me my online records between the dates specified below: 

Please provide me my online records relating to a specific diagnosis, accident or event:		

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 the above under the terms of the GDPR

Please tick:

•	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:
(a) has consented to my making this request, or 
(b) is incapable of understanding the request (delete as appropriate) 
•	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)

Signature of applicant: ...................................................... 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.