Data - You will appreciate that health data relating to any individual is highly confidential and the Practice must ensure that it releases such data only to the person to whom it relates, or to a person authorised to act on his or her behalf. If you require any health data, please complete this Request Form as fully and accurately as possible to enable us to locate the exact information you require.

Timescales - The Practice will deal with your request as quickly as possible. If you request copies of all or part of your medical record, these will be ready within the allocated timescales specified by the Regulations (which is currently 28 days from receipt of your accurately completed form and confirmation of consent). Under certain circumstances, this period can be extended to 3 months. 

Please note that if you select Summary report of your medical records 2.1 & 4.1 below – we will provide this information within 7 working days. 

Fees - We will not make a charge for the first request for access to your medical records. We may, however, charge for subsequent requests or if we deem that the volume of information requested is excessive. 

If you do not need a Summary Report or Online Access and you need a Subject Access Request, please skip this section and move onto the next page. Otherwise, please select what you need.

If you require a Summary Report, you can request this by emailing sxicb-wsx.ahp@nhs.net or submitting an eConsult for administrative help, you do NOT need to complete this form.

If you require Online Access. You can request this yourself via the NHS App.

STOP - If you have selected 2.1 or 2.2 then no need to complete the rest of this form

Fees - We will not make a charge for your first Subject Access request. However, we will charge for any subsequent requests. The cost for all subsequent requests is currently £50 – as of October 2023. We may, also charge if we deem that the volume of information requested is excessive. 

Please tick the relevant box below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. 

Please complete if you are requesting access on behalf of the above-named patient

Please specify what information you are requesting – (please tick one box Only)

Reason for access

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 UK Data Protection Act 2018.  

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.

Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records. 

Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this. 

If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then they will be competent to give consent for themselves.  

They may wish a parent to countersign as well. 

Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well. 
If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below.

You will be telephoned when the copies are ready for collection or posting.