Subject Access Request - Electronic Medical Records

Please complete this form to request access to any aspect of your medical records, which will be provided in an electronic format. If you have access to your receords via the NHS app you will not need to complete this form as you already have access via your digital device.

Last Updated: 24/07/2024

Patient Details

Name of Patient *

Date of Birth *

Address *

NHS Number

E-mail address *

Request Details

Do you require a copy of the entire Elecrtronic GP record? *

Yes No

Details of the request (what is it you are requesting - please provide dates where relevant. Please note we provide electronic records as standard) *

I am the representative of the following individual and would like to make a subject access request for their personal information.

Is the request made on behalf of another individual? *

Yes No

If yes, what is the name and contact details of the requester?

Please provide the basis for applying on behalf of another individual (please note that the practice may need to contact you to verify the option chosen) *

I hold lasting power of attorney for the patient.

I am appointed as an independent mental capacity advocate on behalf of the patient

I have parental responsibility and the patient is under 18 years, and lacks capacity to understand the request.

I have parental responsibility and the patient is under 18 years and has consented to the request.

Authorisation

You will need to provide documentation and photographic evidence when you collect the request from the surgery.

Signature (by printing your name this constitutes an electronic signature) *

By printing my name below I accept that the electronic records I receive, containing my GP electronic records, are my responsibility and that I am accountable for the management of such records once the documents are received. *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Hampton Medical Centre website

Subject Access Request - Electronic Medical Records

Further Information