Access to Records

Date of Birth*

NHS Number (if known)

Record Requested

The more specific you can be, the easier it is for us to quickly provide you with the records requested.

Date from*

Date to*

Details and declaration of applicant

Please enter details of applicant if different from Section 1

Evidence of the patient's and/or the patient representative's identity will be required. Please attach copy of the required documentation to this application form. Examples of required documentation are:

	Type of Applicant	Type of documentation
A	An individual applying for his/her own records	One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card etc.
B	Someone applying on behalf of an individual (Representative)	One item showing proof of the patient's identity and one item showing proof of the representative's identity (see examples in A above)
C	Person with parental responsibility applying on behalf of a child	Copy of birth certificate of child & copy of correspondance addressed to person with parental responsibility relating to the patient
D	Power of Attorney/Agent applying on behalf of an individual	Copy of a court order authorising Power of Attorney/Agent plus proof of the patient's identity (see examples in A above)