Online Proxy Access Form

Application for Patient Online Access to Medical Records Proxy Access Requested

Name
Date of Birth
Address
I wish to have access to the following online services (please tick all that apply):
I wish to access my medical record online and understand and agree with each statement
The Practice makes every effort to record information as accurately as possible, however, there may be information that you do not feel is correct.

Proxy Access to be granted to:

Name
Date of Birth
Are you registered at our organisation?
Address

Electronic Health Record Access

What 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?
At 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.