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Patient Authority Consent Form

IMPORTANT – Please read these notes before you proceed with your application.

The General Data Protection Regulations and Data Protection Act 2018 gives every person the right to apply for access to their health records. Any request for access to health records must be made in writing or electronically to your local GP, for GP records or the Records Manager at the hospital, for your hospital records.

Under the GDPR Act 2018 , there is no obligation to comply with an access request unless the health professional has such information as he or she needs to identify the applicant and locate the information.

Once the health professional has all the relevant information, they should comply with request promptly within 28 days. In exceptional circumstances if it is not possible to comply within the 28 day period the applicant should be informed.

Under the GDPR Act 2018 there are certain circumstances in which the record holder may withhold information. Access may be denied, or limited, where the information might cause serious harm to the physical or mental health or condition of the patient, or any other person, or where giving access would disclose information relating to or provided by a third  person who had not consented to the disclosure.

If you are applying for a patient that is not capable of giving his or her permission, this form should be signed by

  • a ‘litigation friend’ acting for the patient;
  • someone with ‘ enduring Power of Attorney’ to act for the patient: or
  • a receiver appointed by the Court of Protection.

Complaints about any aspect of an application to obtain access to health records should be discussed firstly, with the health professional. If this avenue is unsuccessful a complaint can be made under the NHS Complaints Procedure.  Having followed the procedure and being dissatisfied with that outcome of the investigation a person does have the right to take their complaint to the Health Service Ombudsman, or as a last resort, to court. Alternatively, a person has the right to complain to the Information Commissioner, at Wycliffe House , Water Lane, Wilmslow, Cheshire SK9 5AF. Tel: 01625 545700 or

Costs: There is no charge for a routine request but we may charge for the following: 
Repeat, unfounded or excessive requests.

Finally, please ensure you have filled in the details on the consent form and sign it. You may wish to keep a copy for yourself. Thank you.

Patient Authority Consent Form to Health Records under the General Data Protection Regulations 2018 & Data Protection Act 1998 (Subject Access Request) Patient’s authority for release of health records (Manual or Computerised Health Records)
If applying on behalf of the patient please complete the details below:

To help us save time and resource, if you wish, it would be helpful if you could provide details, informing us of periods and parts of your health records you require, along with details which you may feel have relevance e.g. consultant name and location etc.

Optional - Please use this table below to inform us of certain periods and parts of your health records you may require. This may include specific dates; consultant name and location, and parts of the records you require, i.e written diagnosis and reports.

Example 1st March 2008 to 31st March 2015 – All my GP notes and the consultant reports of my GP concerning back pain within this period.

I am applying to access my health records under the GDPR Act 2018 and Data Protection Act 1998

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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