Patient Access to Medical Records – Request Form

Patient Details

First Name *

Last Name *

Date of Birth *

NHS Number (if known)

Phone Number *

Email Address *

Home Address *

What is being applied for (tick as applicable):

I am applying for access to view my health records

I am applying for copies of my health record

I am applying for copies of another patients records

Additional details:

You do not have to give a reason for applying for access to the health records. However, to help the Practice save time and resources, it would be helpful if you could provide details below, informing us of periods and elements of the health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports etc.

Please tick the appropriate box: *

I am applying to access my health records.

I have instructed my authorised representative to apply on my behalf. E.G. Third party, parental or carer.)

I am applying to access a deceased patient’s record – Under the Access to Health Records Act 1990.

Representative’s Details

First Name *

Last Name *

Phone Number *

Email Address *

Home Address *

I confirm to give permission for the Practice to communicate with my authorised representative in regards to my medical records.*

Please detail below if the above access is to be limited in any way (e.g. a specified time period only):

Please provide a copy of proof of identity.

Drag & Drop files here or click to browse

Upload

Acceptable file formats are JPG, PNG OR PDF. The combined file size should not exceed 3MB.

I want a copy of the contents of this form to be emailed to me

I confirm that I am a registered patient at Marlborough Surgery*

Fields marked with an asterisk (*) are mandatory

Patient Access to Medical Records – Request Form

Patient Details

What is being applied for (tick as applicable):

Please tick the appropriate box: *

Representative’s Details

Patient Info

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