Access to Information Department
The Royal Liverpool & Broadgreen University Hospital NHS Trust
Prescot Street
Liverpool
L7 8XP
0151 706 3232/2681
ACCESS TO PERSONAL DATA APPLICATION FORM
ACCESS TO HEALTH RECORDS ACT 1990/DATA PROTECTION ACT 1998
To access records for a living individual - Data Protection Act 1998.
To access records for a deceased patient - Access to Health Records Act 1990
Please complete in BLOCK CAPITALS and BLACK INK
Details of the person whose information is being requested
Mr, Mrs, Miss or Ms: ………………..
DOB: ……………………………………..
Forenames: …………………………..
Surname: ………………………………..
Address: ………………………………
Contact Number: ……………………….
…………………………………………..
Previous Surname: …………………….
…………………………………………..
Previous Address: ……………………..
Postcode: ………………………………
……………………………………………
……………………………………………
Applicant’s Details (if different to above)
Forename: …………………………………..
Surname: …………………………………..
Relationship to Patient: …………………….
Address: ……………………………………..
………………………………………………...
Postcode: ……………………………………
………………………………………………...
Contact Number: ………………….............
Please tick box/s below:
□
□
□
□
□
I am the patient
I am acting on behalf of the patient and they have completed the authorisation section
I am acting on behalf of the patient who is unable to complete the authorisation section
I am the deceased patient’s next of kin or personal representative
I have a claim arising from the patient’s death and wish to access information relevant to
my claim
Signature: …………………………………..
Date: …………………………………
Details of the records you require
Health records dated from ___/___/______ to ___/___/______
Give full details of all the episodes of treatment in which you are interested in, and if you only
wish to receive data relating to a special aspect of an episode, please specify in the
comments section:
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
…………………………………………………………………………………………..………………
…………………………………………………………………………..………………………………
…………………………………………………………..………………………………………………
Please note records will only be supplied up to the date this application form is completed. If
any further records are required in the future a new application has to be submitted.
Are copies of x-ray films required?
Yes/No
Please note copies of x-rays are available on CD Rom only
Details of the records you require
Information dated from: ____/___/______ to ___/___/______
Please provide as much information as possible and give full details of any emails, HR
records or personal information in which you are interested in below:
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
…………………………………………………………………………………………..………………
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Reason For Access (please tick)
□ Complaint/Claim against Hospital
□ Personal Use
□ Other
Type of Request (please tick)
□ I wish to view the Health Records at the Trust only
□ I wish to receive copies of my records
Declaration
I declare that the information provided above is correct to the best of my knowledge
For the purposes of identity verification, can you enclose a copy of one the following forms of
ID:
□ Passport
□ Driving Licence
□ Birth Certificate
□ Bus Pass
□ Other (please state) ………………………………………………………………………..
On Collection:
Signed:
…………………………...
ID Checked:
……………………
Print Name:
……………………………
Date:
……………………
On receipt of this completed form a letter of acknowledgment will be sent to the
applicant