I declare that information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act.
Please select one box below:
q I am the patient/client/staff member (data subject).
q I have been asked to act on behalf of the data subject and they have completed section 4 -authorisation above.
q I am acting on behalf of the data subject who is unable to complete the authorisation section above (Covering letter with further details supplied).
q I am the parent/guardian of a data subject under 16 years old who has completed the authorisation section above. (Please include proof such as birth certificate)
q I am the parent/guardian of a data subject under 16 years old who is unable to understand the request and who has consented to my making the request on their behalf.
q I have been appointed the Guardian for the patient/client, who is over age 16 under a Guardianship order (attached).
q I am the deceased patient/client’s personal representative and attach confirmation of my appointment.
q I have a claim arising from the patient/client’s death and wish to access information relevant to my claim (Covering letter with further details to be supplied).