Online Proxy Access Form Application for Patient Online Access to Medical Records Proxy Access Requested Name First Last Date of Birth Day Month Year Address Street Address Address Line 2 City / Town County Post Code Email PhoneI wish to have access to the following online services (please tick all that apply): Booking appointments Requesting repeat prescriptions Access to tests results Accessing my prospective full medical record Select AllI wish to access my medical record online and understand and agree with each statement I agree to my GP Practice giving me access to my record online I have read and understood the patient guide about online access to medical records and test results I will be responsible for the security of the information that I see or download I agree to use the system in a responsible manner. If not access may be withdrawn. If I choose to share my information with anyone else, this is at my own risk I agree that it is my responsibility to keep my username and password secure. If I think these have been shared inappropriately, I will reset them using the instructions supplied. I am also responsible for keeping safe any information I may print from the record. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible If I see information in my record that is not about me immediately log out and report the matter to the Practice as soon as possible. If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible. I understand that online access is granted at the discretion of the Practice, taking into account my best interests. I will be informed of any decision not to provide access or withdraw access. Please note, this does not affect your rights of Subject Access under the Data Protection Act. I agree that my details below may be used to contact me about how useful I find the service and whether it could be improved The Practice makes every effort to record information as accurately as possible, however, there may be information that you do not feel is correct. If I notice any inaccuracies with my record, I will inform the Practice as soon as possible of any errors or omissions I understand that I may see information on my record that I was unaware of or have forgotten about that could cause me distress. I agree to use the system in a responsible manner in accordance with all instructions given to me by the Practice. If not access may be withdrawn. I understand that, I will be informed by the Practice of any test results that require action. However, I understand that I may see these results online before the Practice has been able to contact me. This could be while the Surgery is closed and there is no one available to discuss with me. I understand that if I may see information in documents that relates to significant diagnosis before my GP or hospital specialist has the opportunity to discuss my diagnosis, prognosis and treatment options with me and that this could cause me distress. I understand that there may be medical terminology used within my records that I do not understand and that it will take time to arrange for a member of the team to be able to explain the relevant terminology with me and that this could cause me distress. SignatureProxy Access to be granted to:Name First Last Date of Birth Day Month Year Relationship to patient Are you registered at our organisation? Yes No Address Street Address Address Line 2 City / Town County Post Code Email PhoneSignatureElectronic Health Record AccessWhat is coercion? “Coercion” is the act of governing the actions of another by force or by threat, in order to overwhelm and compel that individual to act against their will. Online services of all types are vulnerable to coercion. In the context of Patient Online, coercion might result in patients being forced into sharing information from their record, including login details, medical history, repeat prescription orders, GP appointment booking details and other private, personal information. Would someone else ask for your access to your medical information if you were given on-line access? Yes No SignatureAt present we are automatically giving patients access to certain aspects of their medical records, these are Problems, Medication and Allergies. By signing this form you are agreeing that you are happy with this.