Application for Access to Health Records

Please complete this form if you want to make a request about your personal data held by the practice.

You can use this form to request access to your personal data, ask us to correct information, ask us to restrict processing, object to processing, or ask us to erase data where this applies.

You do not have to use this form

You do not have to use this form to make a request.

However, completing it will help us deal with your request more efficiently.

What you can request

You can use this form to ask the practice to:

provide access to your personal data
correct information we hold about you
restrict how your data is processed
erase data we hold about you, where this applies
consider an objection to the processing of your personal data

Your right to restrict data processing

Your right to restrict data processing only applies in limited circumstances.

This may apply if:

there is a query about the accuracy of personal data we hold, while we check whether it is accurate
the processing is unlawful, but you want us to restrict its use instead of deleting it
the information is no longer needed for its original purpose, but you need us to keep it for legal reasons
you have objected to us processing your personal data, while we check whether our reasons for processing override your objection

Your right to have data erased

Your right to have data erased only applies in limited circumstances.

This may apply if:

your personal data is no longer needed for the purpose it was originally collected
the basis for processing your data is consent and you have withdrawn that consent
the basis for processing your data is legitimate interests, but our reason does not override your interests
your personal data is being processed for direct marketing and you object to that processing
we have processed your personal data unlawfully
there is a legal obligation to erase the data, such as a court order
the data is being processed to offer certain digital services to a child

In most cases, the practice is required to keep medical records in line with legal and public health requirements, including to make sure you receive the correct healthcare treatment.

This means we may not be able to erase information from your medical record unless the legal conditions for erasure are met.

Your right to object

Your right to object only applies to certain types of processing. The sections below explain when you can object and what the practice must consider.

Direct marketing, including profiling

You have an absolute right to object.

Legitimate interests, public interest or official authority

You can object at any time for reasons relating to your situation.

We do not have to comply if we have legitimate grounds for the processing.

Scientific or historical research, or statistical purposes

You can object at any time for reasons relating to your situation.

We do not have to comply if the processing is needed for a task carried out for public interest reasons.

If you are making a request on behalf of someone else

You can use this form if you are making a request on behalf of someone else.

If you do this, we may ask you to provide evidence that you are entitled to act on their behalf and receive information about them. We may also seek authority from the person the request is about.

Please make sure you complete the relevant representative section of the form.

Charges for requests

You will not usually be charged for a copy of your records.

However, the practice can charge a reasonable fee if a request is clearly unfounded, excessive or repetitive.

A reasonable fee may also be charged for further copies of the same information.

Section 1: Details of the individual for whom the request relates

Title

Surname

Forename(s)

Address including Post Code

Date of Birth

NHS Number (if known)

Contact Telephone Number

In order, to protect your information, we are unable to respond to a request unless we have confirmed your identity. Please provide one form of identification and one proof of address. If you are posting copies to us, please ensure these are appropriate certified, alternatively please attend the practice with original documents (acceptable documents listed below):

Documents that can be used as proof of Identity:

1. Current signed passport 2. Residence permit issued by the Home Office 3. EU or Swiss national identity photo-card 4. Valid UK photo-card driving licence (full or provisional) 5. Valid armed or police forces photographic identity card 6. Photographic disabled blue badge 7. Citizen card

Please upload the relevant document as proof of identity

Documents that can be used as proof of current address (must be dated in the last six months):

1. Recent original utility bill (i.e. gas, electric, water, telephone - not mobile) 2. Hospital Appointment Letter 3. Council tax bill (valid for current year) 4. Bank, building society or credit union statement or passbook 5. Recent original mortgage statement from recognised lender 6. Current council/housing association rent book or tenancy agreement 7. Notification letter from Department for Work and Pensions / HM Revenue and Customs confirming your right to benefit or state pension

Please upload the relevant document as proof of address

Section 2: Whose personal data are you requesting?

Please select which of the following applies:

I am the patient named in section 1 (please proceed to section 3)
I have a signed letter of authority to make this request
I have parental responsibility for the patient who is under the age of 16 (please enclose a copy of proof of parental responsibility i.e. parental responsibility order issued by the Court or a copy of the Childs full birth certificate)
Please note that you do not have an automatic right to your child’s data
and decisions will be made on the relevance of release of data to you. In the UK a child aged 13 years or older in most circumstances will be required to consent to the release of their data
I have been appointed through a Lasting Power of Attorney to act on behalf of the patient (N.B. proof must be enclosed before the application can be processed i.e.
a copy of the sealed document)
Other Reasons (please outline)

Other reason

If you are not requesting access to your own personal data, please provide the following information about you:

Full Name

Address to include postcode

Date of Birth

Contact Telephone Number

Relationship to individual for whom you are requesting data:

PLEASE NOTE: If you are not requesting access to your own personal data, we are unable to respond to your request until we also receive the following:

• Satisfactory confirmation of the identity of the person on whose behalf you are making this request. Please provide details outlined in section one.

• A copy of your legal authority to make this request. This may be a signed letter of authority, a power of attorney document or other legal document confirming you are their legal representative

Section 3: What data are you requesting?

Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification, or objection. Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.

I declare that the information given in this form is correct to the best of my knowledge and that I am entitled to apply for access to the records referred to under the terms of the UK General Data Protection Regulation (UK GDPR) 2016, Access to Records Act 1990 or the Mental Capacity Act 2005.

Please check the information you have provided and sign below:

Full name of Applicant

If you need to clear your signature from the box above and start it again, click here.

Signature of Applicant

Clark Avenue Surgery

Clark Avenue Surgery

Application for Access to Health Records

You do not have to use this form

What you can request

Direct marketing, including profiling

Legitimate interests, public interest or official authority

Scientific or historical research, or statistical purposes

Section 1: Details of the individual for whom the request relates

Section 2: Whose personal data are you requesting?

Section 3: What data are you requesting?

Appointment System Myth Buster

You do not have to use this form

What you can request

Direct marketing, including profiling

Legitimate interests, public interest or official authority

Scientific or historical research, or statistical purposes

Section 1: Details of the individual for whom the request relates

Section 2: Whose personal data are you requesting?

Section 3: What data are you requesting?