Access to Health Records Request Form

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

Full Name*

Former Name

Current Address*

Street Address
City
Postal Code

Previous Addresses
Street Address City Postal Code Dates

Date of Birth*
DD slash MM slash YYYY

NHS Number (if known)

Contact Number*

Email

2. Tell us who you are

Please tick the box that applies*

I AM the patient the patient/service user and hereby enclose evidence of my identity e.g. photocopy of my driving licence, birth certificate, passport or marriage certificate and something that confirms your home address such as a recent utility bill or council tax letter.

I am NOT the patient/service user but am acting on their behalf as their personal representative/Health and Welfare POA. I have written authority, which I enclose and evidence of their identity e.g. photocopy of driving licence, birth certificate, marriage certificate or passport.

I am NOT the patient/service user, but I am acting on their behalf as their parent or legal guardian and enclose evidence of their identity e.g. photocopy of birth certificate or passport.

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

Full Name

Former Name

Current Address

Street Address
City
Postal Code

Previous Addresses
Street Address City Postal Code Dates

Date of Birth
DD slash MM slash YYYY

NHS Number (if known)

Contact Number

Email

4. Information Requested

Describe the specific information you are requesting: please provide as much detail as possible, such as specific reports, letters, notes, meetings and their dates, etc.*

5. Your Preferences

Please choose one option*

I would like a paper copy of my records

I would like to view my records with a healthcare professional

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.

Full Name*

Date of Request*
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.