Application for copies of records

Please read the Information prior to completing this form.

Please ensure all the fields marked* are filled in correctly.

Particulars of Person whose information is required

Hospital or NHS Number

Former / Maiden Name

Date of Birth*(dd/mm/yyyy) !

Requester's current address* ! !

Email address (this should be the address you wish us to respond to)* ! !

Telephone / Mobile* !

Which of the following do you require (please tick)?

Any Specific Records?

Please note that we may not have direct access to some contracted or shared services such as Gastroenterology, Audiology, Dental or IAPT. If you have attended any of these services and require the notes, please list the services here.

Relationship to Patient (for patients who are living):

Tick here if you are a representative of the patient and review the below requirements

Tick here if you are the parent/guardian of the patient and review the below requirements

I have the patient / client’s written authorisation – please provide a copy (required for any individual aged 13 or over, unless they lack the capacity to provide consent)

(if the subject is unable to provide written authorisation, Please enclose a photocopy of proof of power of attorney / Court Order)

I have proof of parental responsibility (required for any individual aged 12 or under or for those not able to provide consent)

(i.e. Parental responsibility order issued by the court or a Photocopy of Child Full Birth Certificate)

If applying for a deceased patient’s records:

I am a person with a claim arising out of the patient’s death

Please provide one or more of the following proofs and indicate below which you have:

1) A Copy of Letters of Administration or grant of probate

2) A Copy of the relevant section of the Will confirming you are the Executor of the estate

3) Evidence of your claim, the nature of the claim, clarification of the claimant’s relationship to the patient.

All proof documents should be sent to SAR.WhittHealth@nhs.net. Should you wish to send us a secure encrypted message for this purpose, you can do this by registering for a free Egress account here

I have read this form and authorise a subject access request to be carried out.