Access to Health Records Form

Forename*

Surname*

Email Address*

Address*

Tel No.*

May we leave an answer phone message?* yesno

Please tick the appropriate boxes I am a patient and over the age of 16 years.I am the person who had legal responsibility for the patient who is under the age of 14.The patient is over 14 years of age and under 16 years of age has consented to my making this request and has authorised my application.I am acting on behalf of the patient (aged over 16). Please be advised that you will need to provide proof that you have power of attorney or that you are a legal representative.I am the deceased patients personal representative and attach either letters of administration or a grant of probate.I have a claim arising from the patients death and wish to access information relevant to claim on the grounds that:

Name of Patient

Signature

Unless you have requested paper copies, records will be sent out to you via an delivery system. The password to open this document will be emailed to you.

DETAILS OF PATIENT:

Forename*

Surname*

Address*

Date of birth* Please use dd/mm/yyyy format

Title

Gender MaleFemale

NHS Number

Hospital Number

If the name and / or address were different from above during the time period(s) to which the application relates - please give details below:

Previous Surname

Previous Address

Applicable Dates Please use dd/mm/yyyy format

To help the NHS save time and resources it would be helpful if you could provide details below, informing us of the parts of the health records you require, along with details which you may feel have relevance i.e. dates, consultant name, location, written diagnosis and reports etc.

Please use the space below to document, continuing on another page if necessary

Which records are you requesting? (please tick the applicable boxes) WWL Hospital Services (Royal Albert Edward InfirmaryLeighWrightingtonThomas LinacreBoston House)WWL Community Services (Walk In CentreDistrict NurseMental Health etc.)
I consent to the Trust leaving a message on my contact number in regards to my query.

WWL Services:

WWL HOSPITAL / CLINIC CONTACTS (Please provide as much information as possible)

WWL Community:

WWL COMMUNITY CONTACTS (please provide as much information as possible)

Name of Service* (podiatry, Diebetics etc.)

*if you are unsure of the service can you provide detail of the treatment received: mental health, diabetic care etc.

Where were you treated? (Clinic, walk in, home etc.)

Health Professionals Name (if known)

Month and Year of care or treatment (if known) Please use dd/mm/yyyy format

Month and Year of care or treatment ended (if known) Please use dd/mm/yyyy format

Do you wish to arrange an appointment to view the original records in the presence of a member of staff? Please note this will be a member of the Information Governance Team who is not medically trained. yesno

I would prefer to receive the records as paper copies. yesno

In order that we can process your application request efficiently would you please advise us if this application is in connection with an ongoing complaint against the Trust? yesno

If yes, please enter your complaint reference number:

Declaration:

I declare that the information supplied above is correct to the best of my knowledge and that I am entitled to apply for access to the above record(s) under the terms of the Data Protection Act 2018. I enclose two forms of identification one of which must be a photocopy of photographic identification; the other must be a utility bill:

We cannot process your application without proof of identity.

Signature*

Date of birth* Please use dd/mm/yyyy format

Send