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Refer a patient

Subject access request application under the Data Protection Act 1998

Please note that a fee may be charged up to a maximum of £50.00

Persons aged 12+ with capacity must complete

1. Patient details (records to be accessed)
* required
* required
* required
   
* required
* required
* 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:



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






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


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

* required
* required
* required
* required
   
* 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:

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

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

If patient lacks capacity




If child under 12


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

* 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 Data Protection Act 1998.