Form 2
PATIENT AUTHORITY CONSENT FORM
Access to Health Records under the Data Protection Act 1998
(Subject Access Request)
If you are the patient, please complete part 1 only. If you are NOT the patient but are
applying on behalf of the patient, please complete Parts 1 and 2.
Part 1- Patient details
1. Full name (including former name(s))
(please print all details and use dark
ink)
Mr/Mrs/Miss/Ms…………………………………………..
2. Date of Birth:
……………………………………………………………..
3. NHS number (if known)
……………………………………………………………..
4. Current address:
……………………………………………………………..
Former Name(s)………………………………………….
……………………………………………………………..
……………………………………………………………..
(optional)
5. Former addresses (if applicable)
(use separate sheet if necessary)
Tel number (incl. area
code)………………………………………………………
……………………………………………….............
…………………………………………………………
6.
I am applying for access to view my health records/I am applying for copies of my health records
(Delete as appropriate)
Important Information
7.
Under the Data Protection Act 1998 you do not have to give a reason for applying for access to
your health records. However, to help us save time and resources, if you wish, it would be
helpful if you could use the space provided below to inform us of certain periods and parts
of your health record you may require. This may include specific dates, along with details
which you may feel have relevance, i.e. consultant name and location and parts of the records
you require, for example, written diagnosis or reports. You may use a separate sheet of paper if
necessary.
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Below is an example of the type of information which would be helpful. Please complete in
the space provided.
Example:
1st March 2001 – 31st March 2005 All correspondence and consultant reports to my GP concerning
back pain in this period.
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
8.
Identification (please only send photocopies) :
We cannot process your application without proof of identity.
Please indicate which of the following identification documents are enclosed
Driving Licence
OR
Passport/Birth Certificate
And additional proof of address e.g. utility bill
9.
I am applying to access my health records under the Data Protection Act 1998 for health records
held at:
…………………………………………………………. I understand that under the Data Protection Act
1998 (fees and miscellaneous provisions) Regulations 2001, there may be a charge for me to view
or to be provided with a copy of my health records.
10.
Signed………………………………………………… Date:………………………………………..
If you are not the patient but are applying on behalf of the patient, please complete Part 2.
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PART 2
Relative/Guardian/Agent acting on behalf of the patient
If you are not the patient please state your full name and relationship to the patient:
……………………………………………………………………………………………………………………….
Your Address:
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Please state briefly the reason why this application is being made by you
……………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Your Signature…………………………………………………………
Name in Capitals……………………………………………………….
We cannot process your application without proof of identity.
Please indicate which of the following identification documents are enclosed
Driving Licence
OR
Passport/Birth Certificate
And additional proof of address e.g. utility bill
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Part 2 (continued)
The Patient Representative Authority Consent Form below, must be completed and signed by the
patient in order that we can release the information requested.
I give permission for the individual named below to submit this request on my behalf and for all
correspondence to be sent to them.
Name in block capitals:…………………………………………………………………………………………
Signed (patient)………………………………………………………………………………………………….
Name of the person acting on behalf of the patient:…………………………………………………………
Address:………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..
……………………………………………………………….Postcode…………………………………………
Relationship to patient…………………………………………………………………………………………..
(please attach copies of any relevant legal documentation if applicable)
The Medico-Legal Department
Health Records Library
Manchester Royal Infirmary
Oxford Road
Manchester M13 9WL
When completed, please return this form to the above address.
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