Please only use this form to request the records of a living individual under the

Data Protection Act 1998

Email to or by post to Subject Access Request Office, RLBUHT, Prescot Street, Liverpool L7 8XP

Section 1: Patient’s Details

Title: Mr/Mrs/Miss/Ms Mx//Dr/Other
First Name
Last Name
Previous Name (if applicable)
Date of Birth
NHS Number (If known)
Hospital Number (If known)
Home Telephone
Mobile Telephone
Email
Current Address
Post Code
Previous Address including Post Code

Section 2: Applicant details (if you are NOT the Patient)

Title: Mr/Mrs/Miss/Ms/Mx/ Dr/Other
First Name
Last Name
Home /Work Telephone
Mobile Telephone
Email
Your Postal Address including Post Code
Relationship to Patient:
Legal representative/Relative/Friend/
Other (please specify)

Section 3: Details of Records Requested

Please tell us the department attended and the name of the Consultant if possible
Dates:
E.g. date of A&E Attendance
Or date of hospital stay or clinic appointment / Start date / End Date

Do you require copies of X Ray/Scans?

Yes

No

X Ray Date

Reason for request (please tick)

I do not wish to disclose

Personal use

Veteran

Other

Type of Request

I wish to receive copies of my health records

I wish my representative to receive copies of my health records

Patient authorisation to grant access to a nominated representative

I am the patient whose details appear in Section 1 and give authorisation for the applicant whose details appear in Section 2 to be provided access to my health records covering the periods and episodes of care detailed in Section 3

I authorise (Name of Representative)

to receive copies of my health records on my behalf.

.

Consent, Authorisation and Identification

I enclose a COPY of one the following forms of identification to support my application and to prove my identification:

Thank you - Please Do Not send your ORIGINAL Documents in the post

Passport

Driving Licence

Bus Pass

Other formal Photographic ID (please tell us)

Please tick box/s below:

I am the patient whose details appear in section 1 and declare that the information provided is correct to the best of my knowledge

Signature of Patient
Date

Or

I am acting on behalf of the patient in section 1 and they have completed the authorisation and declaration section below

I am acting on behalf of the patient who is unable to complete the authorisation and declaration section below

Signature of Representative
Date

I enclose a COPY of one the following forms of ID to support this application and to prove my identification:

Passport

Driving Licence

Bus Pass

Other formal photographic ID (please tell us)

Fees

Types of health records / Fee
Electronic and /or paper health records which have been updated within the previous 40 days of the application / No cost
Electronic and/or paper health records which have not been updated within the previous 40 days of the application / £10
Copies of electronic health records only / £10
Copies of paper and electronic health records / Up to £50
(RLBUHT will make every effort to keep fees to £10.00 by digitising records whenever possible)

Payment

When we receive your completed form we will contact you to let you know the costs and how you can pay before we send you an invoice.

Additional Information

Please provide enough information as you can, we aim to respond to you as quickly and accurately as possible.

The Data Protection Act 1998 specifies 40 calendar days to comply with all Subject Access Requests, however, Royal Liverpool Hospitals will make every effort to fulfill within 21 days, rather than the 40 days specified in the Data Protection Act 1998.

Please note records will only be supplied up to the date this application form is completed. If any further records are required in the future a new application will have to be submitted.

Requests for additional information can be made within 40 days of a completed request with no charge.

Email to or post to Subject Access Request Office, Ground floor, RLBUHT, Prescot Street, Liverpool L7 8XP

DPA form v3.1 Nov 15