Access to Health Records Form – Holmside Medical Group

Identity of individual about whom information is requested:

Name(Required)

Prefix First Last

Former Name(s)

Prefix First Last

Date of birth(Required)

NHS Number (if known)

Current Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Former Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Dates at former address

Phone(Required)

Records

What is being applied for (tick as applicable).(Required)

In doing so you understand you may have to pay a fee for access or copies of your records.

I am applying for access to view my health records

I am applying for copies of my health record

Reasons for Access

You do not have to give a reason for applying for access to your 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 your health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports etc. Please use the space below to document this information:

Patient or Representative

Please tick the appropriate box, identifying whether you or a representative on your behalf is applying for access.(Required)

I am applying to access my health records

I have instructed my authorised representative to apply on my behalf

Representative Details

If you are the patient’s representative please give details here:

Representative Name

First Last

Representative Address

Street Address Address Line 2 City County Postcode Country

Phone

Representative Consent

I agree to act on the patient's behalf

Patient Consent

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.