Subject Access Request Form

Subject Access Request

If you are human, leave this field blank.

Section

NHS Number:

I am applying for:

Access to view my health records

Copies of my Health Records (from and to)

Date from:

Please use the format DD/MM/YYYY.

Date to:

Please use the format DD/MM/YYYY.

GP Letter

If you require a GP letter, please indicate in the box below the reason for your request and the specific content of the letter. Please note; there is a charge for all GP letters. This charge may be up to £65. You will be notified of the charge prior to collection/the letter being sent to you.

In line with data protection laws, access to medical records will only be granted if the representative completing this form is listed on the patient’s medical records and the patient has consented to them having access.

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