Proxy Online Access to Health Records Request

All patients should have online access to their full record, including the ability to add their own information, as the default position from April 2020, with new registrants of an organisation having full online access to the digital record for their prospective information starting from the date of their registration for online service and not before 31st October 2023.

Last Updated: 26/10/2023

Please provide the Patient Details

Surname *

Forename *

Date of Birth *

Address *

Telephone Number *

Postcode *

NHS Number

I wish to have access to the health records on behalf of the above names patient

Please complete your details in order to provide access to the online records of the patient detailed above.

If you need to add more than one proxy person, please complete a second form.

Surname *

Forename *

Date of Birth *

Address *

Postcode *

Email address *

Telephone *

Mobile number *

Relationship to patient *

Will you be sharing Proxy access with another individual (if yes please indicate their name below)

Record Requested

I wish to have access to the following online services (please indicate those that apply)

Booking Appointments

Requesting Repeat Prescriptions/Medications

Questionnaires

Clinical Record Access

Reason for Access

Please indicate the reason as to why you require this access

Decleration

I wish to access the medical record online of the above patient and understand and agree to each statement

I have read and understood the information provided by the organisation and agree that I will treat the patient information as confidential *

Yes No

I will be responsible for the security of the information what I see or download *

Yes No

I will contact Hampton Medical Centre as soon as possible if I suspect that the account has been accessed by someone without my agreement *

Yes No

If i see information in the record that is not about the patient I will contact Hampton Medical Centre as soon as possible. I will treat any information which is not about the patient as being strictly confidential. *

Yes No

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. By printing my name below I understand that this will be used as an electronic signature

Identification

ID verification is required to ensure that online access is granted only to the patient or their authorised representative(s). All patients will be requested to provide two forms of ID verification in line with the NHS Good Practice Guidance on Identity Verification, and Hampton Medical Centre accepts appropriate forms of ID outlined below:

2 forms of ID, one of which must contain a photo.

Acceptable documents include passports, photo driving licences and bank statements but not utility bills.

Please bring these document to the surgery for verification

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Proxy Online Access to Health Records Request

Further Information