Subject Access Request (SAR) Online Form Section 1 : Patient DetailsName First Former Name Last Optional Date of Birth Day Month Year PhoneAddress Street Address Address Line 2 City Post Code NHS Number (if known) OptionalHospital Number (if known) OptionalIf you are applying to view your own records, please go to Section 2. If you are applying to view another person’s record, please go to Section 3.Section 2 : Record RequestedPlease tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident) I am applying for access to view my records only I am applying for an electronic copy of my medical record I am applying for a printed copy of my medical record Please specify what information you are requesting: I would like a copy of records between specific dates only (please give dates below) I would like a copy of records relating to a specific condition/specific incident only (please detail below) I would like a copy of all my electronic records (held on computer) I would like a copy of all my electronic and paper records since birth Patient SignatureSection 3 : Details and Declaration of ApplicantPlease complete if you are requesting access on behalf of the above-named patient. If more than one person is to be given access then please list the above details for each additional person on a separate sheet of paperName First Optional Last Optional Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional Phone OptionalRelationship to Patient Optional Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident) I am applying for access to view the records only Optional I am applying for an electronic copy of the medical record Optional I am applying for a printed copy of the medical record Optional Please specify what information you are requesting: I would like a copy of records between specific dates only (please give dates below) Optional I would like a copy of records between specific dates only (please give dates below) Optional I would like a copy of all the electronic records (held on computer) Optional I would like a copy of all the electronic and paper records since birth Optional Reason for access: I have been asked to act by the patient Optional I have full parental responsibility for the patient and the patient is under the age of 18 and has consented to my making this request OR Optional I have full parental responsibility for the patient and the patient is under the age of 18 and is incapable of understanding the request Optional I have been appointed by the Court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so Optional I am acting in loco parentis and the patient is incapable of understanding the request Optional I am the deceased person’s personal representative and attach confirmation of my appointment (grant of probate/letters of administration) Optional I have written, and witnessed, consent from the deceased person’s personal representative and attach Proof of Appointment Optional I have a claim arising from the person’s death (please state details below) Optional Details if you have selected "I have a claim arising from the person’s death" OptionalDeclaration I declare that the information given by 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 UK Data Protection Act 2018. You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution. OptionalApplicant Signature OptionalPatient Signature OptionalI confirm that I give permission for the organisation to communicate with the person identified above regarding my medical recordsSection 4 : Proof of IdentityPlease upload a copy of your passport as proof of your identity. Please note this document will be held for 7 days or until a staff member confirms the identity.Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records. Section 5 : Consent for ChildrenI am the patient aged 13 – 18 years OptionalIf a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself. They may wish a parent to countersign as well. Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well. If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below.I am the parent/guardian/person with parental responsibility Name Optional Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional Signature OptionalYou will be telephoned when the copies are ready for collection or posting. Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form.Disclaimer You are submitting a Subject Access Request (SAR) in order to receive copies of the information that this practice holds about you. You have been provided with this information along with an Additional Privacy Information notice in order to comply with the UK General Data Protection Regulation (UK GDPR). You are responsible for the confidentiality and safeguarding of the copies of your medical records which have been provided to you. This organisation accepts no responsibility for the copies once they leave the premises. By ticking this box, you are accepting full responsibility for the security and confidentiality of the copies of your medical records.
