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Please complete this form and email a copy of one of the following acceptable proof of identity to firstname.lastname@example.org
Please provide us with dates, hospitals / clinics / wards and health professionals involved in your / the patients care (if known) which are of interest to you. Please provide as much information as possible to assist us in locating the information the health records that you would like to access.
*If you are an authorised representative of the patient, please complete Box B and obtain the patient’s signed authorisation or supply copies of documents giving you right of access under the Mental Capacity Act.
If you are a relative or other person applying for access to information in relation to a deceased patient’s records please complete Box C.
I am applying to access my health records under the current Data Protection Legislation.
I declare that the information I have completed on this form is correct to the best of my knowledge and that I am the person named.
I am applying on behalf of the patient to access their health records under the current Data Protection Legislation.
I am applying for access to the deceased patient’s health records.