• You can use this form to request access to your healthcare records. This form can also be used to request access to the records on behalf of someone else, if you are legally allowed to act on their behalf. This includes making a request for the records of a child or if you are someone's legal representative.

    Please complete all of the relevant sections on this form and send it back to us with your identification to the address shown.

  • 1. Details of the person requesting the information

  • Street AddressCityPostal CodeDates 
  • DD slash MM slash YYYY
  • 2. Tell us who you are

  • 3. Details of the patient/service user (if different to section 1)

  • Street AddressCityPostal CodeDates 
  • DD slash MM slash YYYY
  • 4. Information Requested

  • 5. Your Preferences

  • Declaration

  • I declare that the information given by me is, to the best of my knowledge correct and that I am entitled to apply for access to the information referred to above, under the terms of the Data Protection Act 2018.
  • DD slash MM slash YYYY
  • Once Compton Care has all the required information, and fee, where relevant, your request should be complied with within 30 days or less (for requests made under the Access to Health Records Act 1990 responses may take up to 40 days but where possible we will work to the 30 day deadline). In exceptional circumstances where it is not possible to comply within this time frame you will be informed of the delay and given a timescale for when your request is likely to be met.

    Once your request has been received, we will contact you to conduct the identification process as outlined in Section 2 of this request form.

Clinical Enquiries: 01902 774570, General Enquiries: 0300 323 0250.

Making Everyday Extraordinary.

At Compton Care we partner with people to embrace life with a complex or incurable condition.

Compton Care Group Ltd,
4 Compton Road West, Wolverhampton, WV3 9DH.Compton Care is a registered charity 512387Compton Care Group Ltd. Registered in England No: 1607631