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All questions marked with a * are mandatory

I am: *
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Applicant's Details
Patient's Details
Please included any former names
Please double check you've entered the correct email address
 
 

Help Us To Help You 

Providing a NHS Number means that we can find a patient record more accurately, saving time and resources. 

How to find your NHS Number 

If known
Would there have been a former postal address we would have on record?: *
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Records requested

Please tick the relevant box below:

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Proof of Authority

If you are making an application on the behalf of somebody else we require evidence of your authority

Please upload a copy of your evidence

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Identification
NHS Logo

Patient Identification

Help us to help you

You must provide proof of identity when submitting a Subject Access Request. Providing proof of address is also helpful, as it allows us to process your request more quickly.

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of your ID and/or Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Declaration

You are requesting access to the records for

  • Name: 
  • NHS Number: 

Please return to the previous pages to make any amendments

  • 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

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