Subject Access Request Form

You will appreciate that health data relating to any individual is highly confidential and the Practice must ensure that it releases such data only to the person to whom it relates, or to a person authorised to act on his or her behalf. If you require to see any health data, please complete this online Request Form as fully and accurately as possible to enable us to locate the exact information you require.

The General Data Protection Regulations (GDPR) gives you the statutory right of access to any information, manual (paper) or computerised. You may wish to authorise someone else to make your application on your behalf and if you have parental responsibilities you may make an application to see your child’s notes.

You do not have to give a reason for applying for access to your General Practice records. If you do not need access to your entire records, it would be helpful if you would inform us of the periods and area of your health records that you require, along with details which you feel may have relevance (e.g. clinic type, location, dates).

Timescale

The Practice will deal with your request as quickly as possible. The information should be available to you within 28 days of receipt of your accurately completed form and confirmation of consent. Under certain circumstances, this period can be extended to 3 months but we will keep you informed of the progress of your request during this extended period.

Fees

We will not make a charge for the first request for access to your medical records. We may, however, charge for subsequent requests or if we deem that the volume of information requested is excessive. You have the right to simply view your records (i.e. not receive a copy in a permanent form); information on how to arrange this is detailed below.

Type of request

If you request to see the original records, you will be invited to make an appointment at a mutually convenient time to view them. If you request copies, these will be ready within the allocated timescales specified by the Regulations, and we will telephone you when they are available for you to come to the Practice to collect them.

Proof of identity

Two forms of identity must be provided (one of which must be photographic). This is to ensure information is not released to unauthorised individuals. The table below outlines the proof of identity we can accept.

Types of identification you can use
Type of application	Identification required
Patient applying for their own. Can be waived if the applicant is known to the Staff Member accepting the request	One which must be photographic i.e. passport. One containing individuals name and address
Third Party Applying. Consent of Patient will be required before the request will be processed	One containing Third Party name and address One must be Photographic ID of Third Party
Applying on behalf of a child We will always obtain consent for release of records from a child age 13+ to <16 if a third party is making request	One which must be Child’s birth certificate Photographic ID of person with parental rights

If you are completing this application on behalf of another person, the Practice will require their authorisation before we can release the data to you. The person whose information is being requested should sign the relevant section within the online form. If the patient is a child (i.e. under 16 years of age) the application may be made by someone with parental responsibilities – in most cases this means a parent or guardian. If the child is capable of understanding the nature of the application, his or her consent should be obtained or, alternatively, the child may submit an application on their own behalf. Children will, generally, be presumed to understand the nature of the application if aged between 13 and 16 however, all cases will be considered individually.

Applicant Details

First Name

Last Name

I am requesting

Please note if you are not the patient, and you have the permission of a third party to act on their behalf, then both persons must be present when completing this online form.

We will require them to complete “The Authorisation of Patient if Request made by Third Party” declaration shown below. This section will appear at the end of the online form.

If this section is not completed, we cannot process the subject access request.

Date of birthDD/MM/YYYY

Preferred Phone number

The Medical Records of another Adult

Name of adult

Address of adult

Date of birth of adult

The Medical Records of a Child

Name of child

Address of child

Date of birth of childDD/MM/YYYY

Type of Request

I wish to request

If selected 'Other' please specify

Copy of Parts of Medical Records

Please provide dates and details of results required

Please provide dates and details of Immunisation summary

Please provide dates and details of Referral Letter(s)

Please provide dates and details of Clinic Letter(s)

If selected 'Other' please specify

Medical Records

Date range of medical records required

Consent

Tick which applies

I am the Patient

I have been asked to act by the patient as detailed and who has completed the authorisation section

I am the parent/guardian of a patient who is between the age of 12 years old and 16 years old who has signed the authorisation section

I am the parent/guardian of a patient who is under 12 years old who is unable to understand the request

Confirm the name of the applicant

Authorisation of patient if request made by a third party

I authorise the Practice to release Personal Data requested relating to me to the above applicant to whom I have given my consent to act on my behalf.

Patients Name

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Ongar Health Centre • Ongar War Memorial Medical, Fyfield Road, Ongar, Essex, CM5 0AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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