Subject Access Request – Access to Medical Records

Introduction

In accordance with the General Data Protection Regulation, patients (data subjects) have the right to access their data and any supplementary information held by Lees Medical Practice. This is commonly known as a data subject access request (DSAR). Data subjects have a right to receive: • Confirmation that their data is being processed • Access to their personal data • Access to any other supplementary information held about them Options for access As of April 2016, organisations have been obliged to allow patients access to their health record online. This service will enable the patient to view coded information held in their health record. Prior to accessing this information, you will have to visit the organisation and undertake an identity check before being granted access to your records. In addition, you can make a request to be provided with copies of your health record. To do so, you must submit a Data Subject Access Request (DSAR) form. This can be submitted electronically and the DSAR form is available on the organisation website. Alternatively, a paper copy of the DSAR is available from reception. You will need to submit the form online or return the completed paper copy of the DSAR to the organisation. Patients do not have to pay a fee for copies of their records. Time frame Once the DSAR form is submitted, Lees Medical Practice will aim to process the request within 21 days; however, this may not always be possible. The maximum time permitted to process DSARs is one calendar month. Exemptions There may be occasions when the data controller will withhold information kept in the health record, particularly if the disclosure of such information is likely to cause undue stress or harm to you or any other person. Data controller At Lees Medical Practice the data controller is Julie Rowe and should you have any questions relating to accessing your medical records, please ask to discuss this with the named data controller.

Application Form for Access to Health Records

APPLICATION FORM FOR ACCESS TO HEALTH RECORDS in accordance with the General Data Protection Regulation (GDPR) DATA SUBJECT ACCESS REQUEST

Section 1: Patient details

Your Name(Required)

Title (i.e. Mr, Mrs, Ms, Dr)

Mr
Mrs
Miss
Ms
Dr
Prof.
Rev.
FirstMiddleLast

Your Address(Required)

Street AddressAddress Line 2CityPostcode

Preferred Method of Contact

Email
Phone

Your Email Address

Email AddressConfirm email address

Section 2: Record requested

The more specific you can be, the easier it is for us to quickly provide you with the records requested, for example records in respect of treatment received (e.g. for leg injury following a car accident)

Please provide me with a copy of all records held
Please provide me with a copy of records between the dates specified:
Please provide me with a copy of records relating to the incident specified :
Please provide me with a copy of records relating to the condition specified:

Section 3: Details and declaration of applicant

Please enter the details of the applicant if different from Section 1

Name

Title (Mr, Mrs, Ms, Dr)

Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
FirstLast

Address

Street AddressAddress Line 2CityPostcode

Telephone number

Section 4: Declaration

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 GDPR.

Please select:

I am the patient

I have been asked to act by the patient and attach the patient’s written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18 and: (a) has consented to my making this request, or (b) is incapable of understanding the request

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

I am acting in loco parentis and the patient is incapable of understanding the request

I am the deceased person’s personal representative and attach confirmation of my appointment (grant of probate/letters of administration)

I have written, and witnessed, consent from the deceased person’s personal representative and attach proof of appointment

I have a claim arising from the person’s death (please state details below)

Signature

Date

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.

Section 5: Proof of identity

Please indicate how proof of ID has been confirmed. Please select ‘A’ or ‘B’:

Attached copies of documents as noted in section 4A below
Countersignature (section 4B). This should only be completed in exceptional circumstances (e.g. in cases where the above cannot be provided)

5A – Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are:

A: An individual applying for his/her own records. One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. B: Someone applying on behalf of an individual (Representative). One item showing proof of the patient’s identity and one item showing proof of the representative’s identity (see examples in ‘A’ above) C: Person with parental responsibility applying on behalf of a child. Copy of birth certificate of child and copy of correspondence addressed to person with parental responsibility relating to the patient D:Power of Attorney/Agent applying on behalf of an individual. Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)

5B: Countersignature

This section is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if 4A cannot be fulfilled.

I (insert full name)

FirstLast

Certify that the applicant (insert name)

FirstLast

has been known to me personally as …………………………………… for ……………………..years (insert in what capacity, e.g. employee, client, patient, relative etc.) and that I have witnessed the signing of the above declaration.

I am happy to be contacted if further information is required to support the identity of the applicant as required.

FirstLast

Signature

Date

Profession

Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.

Address

Street AddressAddress Line 2CityPostcode

Phone

Additional notes

Before returning this form, please ensure that you have: a) Signed and dated this form b) Enclosed proof of your identity or alternatively confirmed your identity by a countersignature c) Enclosed documentation to support your request (if applying for another person’s records) Incomplete applications will be returned. Please therefore ensure you have the correct documentation before returning the form.

Introduction

Application Form for Access to Health Records

Section 1: Patient details

Section 2: Record requested

Section 3: Details and declaration of applicant

Section 4: Declaration

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.

Section 5: Proof of identity

5A – Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are:

5B: Countersignature

Additional notes

Thank you for your feedback.