NHS CONFIDENTIAL

APPLICATION FOR ACCESS TO HEALTH RECORDS/

STAFF RECORDS

(Data Subject Access Request)

Notes for Applicants

With reference to your application for access to the following records would you please fill in the details requested on this form and return to the appropriate person who will process your request, at the address shown below.

As proof of identity you will need to include a copy of your driving license, passport or a utility bill. Your request cannot be actioned without this evidence.

A standard administration fee of £10.00 is made under the Act and upon receipt of this sum we shall commence the procedure to provide you with the necessary information.

Please make cheques or Postal orders payable to Northumbria Healthcare NHS Trust (Cobalt). Please do not send cash.

Please note that if you are making an application on behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order etc.

At a later stage we may need to provide you with photocopies of the records and where this is necessary you will be informed in advance of any charges. (Current charges are 31p per paper copy, plus postage. X rays are charged at £10 per film copied or £40 blanket charge, whichever is the smaller.)

Please note Access to Health Records Act 1990 was replaced by Data Protection Act 1998 except for sections relating to deceased patients which remain in force pending further legislation.

Please note that in relation to any decisions that are made by various departments within the Trust, the Information Governance Department will be unable to give any reasons behind these decisions. We are only able to assist in providing subjects with the information that they have requested. If you have any queries regarding any decisions made please direct these to the department concerned.

If the application is for health records please return the form and fee to:

Medico-Legal Officer, Health Records Department, Northumbria Healthcare NHS Foundation Trust, Northumbria House, Silver Fox Way

Cobalt Business Park, Newcastle upon Tyne, NE27 0QJ

Tel: 0191 2031452 Fax: 0191 2031473

If the application is for any other records please return the form and fee to:

Information Governance Manager, Computer Services Department, Northumbria Healthcare NHS Foundation Trust, Northumbria House, Silver Fox Way

Cobalt Business Park, Newcastle upon Tyne, NE27 0QJ

Tel: 0191 2031645 Fax: 0191 2934283

Office Use:

DPA Ref

/

APPLICATION FOR ACCESS TO HEALTH RECORDS/

STAFF RECORDS

(Data Subject Access Request)

For Health Records please could you complete the Section A

A. Details of the record to be accessed:

Data / Surname / ______
Subject / Forename(s) / ______
Date of Birth / ______/______/______
Address / ______
______
NHS No if known
Hospital reference No if known
Record in respect of treatment for
(State condition/illness if known)
Approximate date ______/______/______

For Staff Records please could you complete Section B

B. Details of the record to be accessed:

Data / Surname / ______
Subject / Forename(s) / ______
Date of Birth / ______/______/______
Address / ______
______
ESR assignment if known
Department worked in if known
Records in respect of
Approximate dates from ______/______/______
to ______/______/______

If applying on behalf of the data subject please could you complete Section C

C. Details of applicant

Name / Surname
Forename(s)
Address


Declaration:

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the records referred to above under the terms of the Data Protection Act 1998. (Please note that someone who knows you should witness your signature and should sign and complete the witness statement below.)

Please delete as appropriate:

*  I am the data subject.

*  I have been asked to act by the data subject and attach their written authorisation.

*  I am acting in loco parentis and the data subject is under age 16 and (is incapable of understanding the request) has consented to my making this request.

*  I am the deceased patient’s personal representative and attach confirmation of my appointment.

*  I have a claim rising from the patient’s death and wish to access information relevant to my claim on the grounds that:

Signed / Date

As proof of identity you will need to include a copy of your driving license, passport or a utility bill. Your request cannot be actioned without this evidence.

Witness Statement:

I certify that I am (Name)
Of (address)

that I have known the applicant for ______years as an employee/client/patient/personal friend* and have witnessed the applicant sign this form

Signed / Date

·  Please delete as appropriate.

Official use only

Fee (£10) received/not appropriate / Signed / ______/ Date / ______
Health professional advising (Name) / ______
Access provided on (date) / _____/_____/_____
Further action: / Corrections requested / Yes/No
Applicant notified outcome / Yes/No
Copies provided / Yes/No
Copying fee (£______) / Yes/No
Postage (£______) / Yes/No
Comments

Data Protection Subject Access Request – Access to Records Form