Subject Access Request Form

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Patient's Details
Please included any former names
Please double check you've entered the correct email address
Additional Information
e.g. radiology results, information relating to a specific accident
Applicant's Details
Proof of Authority
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Details of where medical records are to be sent
Declaration

If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.

Under the terms of the Data Protection Act, Subject Access Requests will be responded to within one calendar month after receiving all necessary information and/or fee required to process the request.

Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.

Please note that we will contact the patient by telephone (using the information on their records) to verify the patients request and identity

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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