Subject access request application under the General Data Protection Regulation (GDPR)

Subject access request application under the General Data Protection Regulation

Persons aged 13+ with capacity must complete

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

1. Patient details (records to be accessed)

Surname: *Required

Forename(s): *Required

Date of birth: *Required

Address: *Required

Telephone number: (Type number in full with no spaces) *Required

Email: *Required

If the name and/or address was different from the above during the period(s) to which this application relates, please give details below:

Previous forename/surname:

Previous address:

2. Details of applicant (if you are not the patient shown above)

Surname:

Forename:

Address:

Telephone number: (type number in full with no spaces)

Email address:

Relationship to patient:

NB: Consent may be sought from the individual detailed in section 1

NB: Parents requesting records on behalf of a child must provide proof of parental responsibility

3. Information required

I wish to view the health records with an appropriate member of staff

Yes

I require photocopies of the requested health records

Yes

Is this request in relation to a claim against Medway Community Healthcare? *Required

Yes

If yes, please provide details:

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

Details of treatment episode eg condition / illness: *Required

Service providing treatment eg tissue viability: *Required

Location of treatment eg clinic, hospital, Healthy living centre: *Required

Date from: *Required

Date to: *Required

4. Identification

You must provide 1 primary and 1 secondary form of identification for patient and also for the applicant if different from patient:

Forms of primary identification. Please attach one of the following: current passport, driving licence or birth certificate. *Required

Forms of secondary identification (Dated within last 3 months). Please attach one of the following: council tax bill, utility bill or other bill or statement addressed to you. *Required

If patient lacks capacity

Enduring/Lasting Power of Attorney for Health and Welfare:

Evidence of appointment as independent Mental Capacity Advocate:

If child under 13

Birth Certificate, Adoption certificate or child benefit letter:

If you are unable to provide ID or have any questions about completing this form, please phone 01634 334640.

5. Delaration: *Required

I understand it is an offence to attempt to obtain information relating to another person without lawful grounds to do so. I declare that the information given on this form is correct to the best of my knowledge and I am entitled to apply for access to these health records under the General Data Protection Regulation.

I agree to the privacy policy.

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Subject access request application under the General Data Protection Regulation (GDPR)