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Request under Access to Health Records Act 1990



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Request under Access to Health Records Act 1990

Request under Access to Health Records Act 1990

There may be a charge for this information.
1. Patient details (records to be accessed)
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If the name and/or address were different from the above during the period(s) to which this application relates, please give details below:



2. Details of applicant
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NB: We require confirmation you are the patient's personal representative (section 4) or have a claim arising from the patient's death.

Are you considering a claim against Medway Community Healthcare? * required



3. Information required


In the following fields please provide a brief summary of the type of information you require the health records to cover and the time scale involved

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4. Identification

Applicant must provide 1 primary and 1 secondary form of identification, 1 confirmation of representative and copy of death certificate.

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Please attach one of the following, current passport, driving licence or birth certificate.

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Please attach one of the following, council tax bill, utility bill or other bill or statement addressed to you.

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Please attach one of the following, Enduring/Lasting Power of Attorney for Health and Welfare, Grant of Probate or Letters of Administration, Proof of claim arising from patient's death.

* required

* required
I understand it is an offence to attempt to obtain information relating to another person without lawful grounds to do so. The information requested relates to a deceased patient and I am their personal representative or a person who has a claim arising out of their death, as specified within the Access to Health Records Act 1990.