Form: Application for access to medical records (SAR) 

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All questions marked with a * are mandatory

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 GDPR.

(Please tick as appropriate):

I am: *
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Applicant's Details
Patient's Details
Please included any former names
Please double check you've entered the correct email address

Help Us To Help You 

Providing a NHS Number means that we can find a patient record more accurately, saving time and resources. 

How to find your NHS Number 

If known
Would there have been a former postal address we would have on record?: *
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Additional Information

Things to consider:

  • It will be your responsibility to keep your records safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

  • If you receive a print out, or choose to print out any information from your record, it is also your responsibility to keep this secure.  If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

  • Be careful that nobody can see your records on screen and be especially careful if you use a public computer to shut down the browser and switch off the computer after you have finished. 

For more information about keeping your healthcare records safe and secure please visit the NHS website

Under the Data Protection Act you do not have to provide a reason for applying for access to health records.

  • However to help us save time and resources, it would be helpful if you could provide details informing us of periods and parts of the health records you require access to, along with details which you may feel are relevant
e.g. radiology results, information relating to a specific accident
Proof of Authority

If you are making an application on the behalf of somebody else we require evidence of your authority

Please upload a copy of your evidence

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Details of where medical records are to be sent
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Declaration

You are requesting access to the records for

  • Name: 
  • NHS Number: 

Please return to the previous pages to make any amendments

  • 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 the terms of the Data Protection Act, Subject Access Requests will be responded to within one calendar month after receiving all necessary information and/or fee required to process the request.
  • Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have 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.
  • Please note that we will contact the patient by telephone (using the information on their records) to verify the patients request and identity
I will contact the practice as soon as possible if: *
I consent to my records being emailed to me: *

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. 

Incomplete applications will be returned therefore please ensure you have the correct documentation before submitting the form.

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Privacy Consent

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