Application Form

Please complete the Application for Access to Health Records, sign and date and return with a £10.00 cheque for the administration fee (per application form). Once this is received, the copying of the health records will commence.

Failure to complete the form correctly will hinder the process of the health records being copied. Please state the dates or period from and to you require copies for.

If you require X-rays, please make that clear on the form. These will be copied onto a CD -Rom.

Completion guidelines.

Once the application is received and sufficient details supplied along with the administration fee of a £10 cheque - copying of the notes will commence. In line with the Data Protection Act (1998) the notes will be completed within a 40 day period however we endeavour to meet requests within 21 days providing the application form is complete and the administration fee is received prior to the copying.

Once complete you will receive by post an advice note indicatingthe total charges . Please refer to the application form that on signing you accept the charges may be up to the amount of £50 maximum. If you require only specific dates of health care episodes copied charges are likely to be less than the maximum fee.

Proof of identity

Ealing hospital aims to ensure that only those entitled to view health records have access to them. Please help us avoid the risk of releasing personal information to unauthorised persons, by providing us with proof of your identity:

If you post your application back to us then please makes sure as well as you £10.00 cheque you post copies of the following forms. If you are bringing the form in person you still need to provide these documents.

Two original document – e.g. a household bill (gas, electricity, water, phone), which has your name and address on (All documents will be returned to you)

A photocopy of your driving licence or passport [Do not send originals]

Should you have any urgent enquiries concerning your application please call the Information Department on 020 8967-5789.

WARNING - The making of untrue statements in order to secure access to personal information to which you are not entitled is a criminal offence.

Administration Fees

There will be no administration charge to the patient or applicant if the health records you require are within 21 days of treatment or attendance at this Trust.

In all other cases a £10 administration fee will be charged. This fee in form of a cheque must accompany the application form. Cash is not accepted.

Photocopying Fees

Photocopying fees will be charged at 30p a sheet for the first 100 sheets and thereafter at 10p. a sheet. An invoice will be sent to the patient or applicant as soon as the fee has been calculated.

The chargesforX-rays to be copied on to a CD-Rom is £20.00.

A Maximum fee of £50.00 is set for copying all health records at the time of request. This includes X-Rays.

All cheques should be made payable to EalingHospital NHS Trust

To view records Only.

You will need to complete the application form with proof of identification. You will be contacted to arrange a mutually convenient time for you to visit the Medical Records Department, to read through your health records. If you view only and do not request to have any material copied there will be nocharge. Please note that any medical questions you have cannot be dealt with on this visit. You will need to arrange to see your doctor if you want to discuss your treatment.

Please remember that health records are legal documents and you must not write in the records, remove any papers from them or alter the records in any way. If having read your records you feel that some information needs adding or amending then please put that request in writing to the Trust and, where relevant, we can have the information added to your file.

Please send your application back to:

Patient Access co-ordinator

Information Department

EalingHospital NHS Trust

Uxbridge Road

Southall

Middlesex

VP/2012