APPLICATION FOR ACCESS TO MEDICAL RECORDS
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 – for information from another organisation, you should contact them direct
•	No fees apply for this request unless a request from a patient is manifestly unfounded or excessive.  In these cases, the practice may —
(a) charge a reasonable fee for dealing with the request
(b) refuse to act on the 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 give adequate information (for example full name, address, date of birth, NHS number and details of the reason for your request) so that your identity can be verified and your records located. 

Please complete the SUBJECT TO ACCESS REQUEST FORM 

To see a copy of your health record or to ask to see parts of it relating to specific points, please complete the relevant section(s) of the SUBJECT ACCESS REQUEST FORM and provide this to the practice.

Your medical records will be prepared for you, depending on what information you require access to. 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. Incoming letters where the patient has not been included in are not included in the default access as we are not the author of documents received from other organisations.

When collecting the paper copies of your records please bring proof of your identity e.g. passport, driving licence etc or if someone is collecting them for you, they must bring proof of their identity and written authorisation signed by you to allow them to collect the documentation.

APPLICATION FOR ACCESS TO MEDICAL RECORDS
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		

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

	
Telephone Number		
Relationship to Patient		

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.

Section 2: Record requested 

The more specific you can be, the easier it is for us to quickly provide you with the records requested. For example, records relating to a diagnosis or an 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 with a copy of all records held 
	d

Please provide me with a copy of records between the dates specified below: 

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

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

	

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.