Access to Medical Records | Oakwood Surgery

The practice is registered and fully complies with the Data Protection Act 1998 and General Data Protection Regulation (GDPR) 2018. Any request for access to notes by a patient, patient’s representative or outside body will be dealt with in accordance with the Act. Requests for information should be submitted in writing with the patient’s signed authorisation included for information to be released. For direct requests, patients will be asked to complete a ‘medical consent’ form at Reception. If you require further information, please speak to a member of our Reception Team.

Access to Health Records Request

Details of the Record to be accessed
Name*
Patients Surname Patients Forname(s)
Date of Birth*
DD slash MM slash YYYY
NHS Number*
Please enter a number from 10 to 10.
Address*
Street Address Address Line 2 City Post Code
Details of the Person who wishes to access the records, if different to above
Name*
Patients Surname Patients Forname(s)
Address*
Street Address Address Line 2 City Post Code
Telephone*
Relationship to Patient*
Declaration
Declaration*
- I am the patient
- I have been asked to act by the patient and attached the patient's written authorisation.
- I am acting in Loco Parentis and the patient is under age sixteen, and is incapable of understanding the request and has consented to me making the request
- I am the deceased patient's personal representative and attach confirmation of my appointment
- I have a claim arising the patient's death and wish to access information relevant to my claim on the grounds that (please supply you reasons below)
I declare that the information given to 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 1998.
Upload File*
Accepted file types: pdf, jpg, Max. file size: 128 MB.
Reasoning*
Enter your reasons
Access to Records*
Please use this space below to inform us of certain periods and parts of your health record you may require. This may include specific dates, consultant name and location e.g. written diagnosis and reports.
- I would like a copy of all records
- I would like a copy of records between specific dates only
- I would like copy recordings relating to a specific condition / specific incident only
Date From*
DD slash MM slash YYYY
Date To*
DD slash MM slash YYYY
Please state your specific condition / specific incident*
Date
MM slash DD slash YYYY
Signature*
Use your mouse or touch device to enter your signature

At Oakwood Surgery, we aim to treat all our patients promptly, courteously and in complete confidence.

856 Stratford Road

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Access to Health Records Request

Details of the Record to be accessed

Details of the Person who wishes to access the records, if different to above

Declaration

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