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It collects patient details, requested record scope by treatment dates, incidents, and conditions, and applicant/declaration information including authority basis (patient, authorised representative, parental responsibility, court appointment, in loco parentis, personal representative, or claims arising from death). It also specifies required identity proof evidence types, required documentation examples, signature and date, and warns that incomplete or false statements may lead to prosecution.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-form-for-access-to-health-records-data-subject-access-request-section-1-to-4/306052/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-form-for-access-to-health-records-data-subject-access-request-section-1-to-4/306052.png","ImageObject",442,249,{"name":88,"@type":89},"Aurelia","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who can use this form to request access to health records under the GDPR?","Question",{"text":108,"@type":109},"The form is for the patient, someone acting with written authorisation, a person with parental responsibility (with relevant conditions), a court-appointed manager, someone acting in loco parentis, or a personal representative of a deceased person, among other specified roles.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required in Section 2 to identify the records requested?",{"text":113,"@type":109},"You must specify the treatment in respect of a relevant matter and provide records requested for the date range, the incident, or the condition, using the form’s guided prompts.",{"name":115,"@type":106,"acceptedAnswer":116},"What proof of identity and supporting documents must be provided?",{"text":117,"@type":109},"The applicant must attach copies of required documentation based on the applicant type, such as identity documents and utility bills/medical cards for individuals, or court orders and evidence for representatives and agents.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306052,1790746461,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},1099514068365,"https://ap-avatar.wpscdn.com/avatar/10000253d8d9f28188e?_k=1776742907772140068","APPLICATION FORM FOR ACCESS TO HEALTH RECORDS in accordance with the General Data Protection Regulation (GDPR) DATA SUBJECT ACCESS REQUEST  \nThis form must be completed in blue or black ink and signed in order for us to process your request.  \nSection 1: Patient details  \n\n| Surname |  | Maiden name |  |\n| --- | --- | --- | --- |\n| Forename |  | Title\u003Cbr>(i.e. Mr, Mrs, Ms, Dr) |  |\n| Date of birth |  | Address: |  |\n| Telephone number |  | Postcode: |  |\n| NHS number (if known) |  | Hospital number (if known) |  |\n\nSection 2: Record requested  \nThe more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g. leg injury following a car accident)  \n\n| Please provide me with a copy of records between the dates specified below: |  |\n| --- | --- |\n| Please provide me with a copy of records relating to the incident specified below: |  |\n| Please provide me with a copy of records relating to the condition specified below: |  |\n\nSection 3: Details and declaration of applicant  \nPlease enter details of applicant if different from Section 1  \n\n| Surname |  | Title\u003Cbr>(Mr, Mrs, Ms, Dr) |  |\n| --- | --- | --- | --- |\n| Forename(s) |  | Address |  |\n| Telephone number |  | Postcode |  |\n\nDeclaration  \nI declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the GDPR.  \nPlease tick:  \n􀂅 I am the patient  \n􀂅 I have been asked to act by the patient and attach the patient’s written authorisation  \n􀂅 I have full parental responsibility for the patient and the patient is under the age of 18 and:  \na) has consented to my making this request, or  \nb) is incapable of understanding the request (delete as appropriate)  \n􀂅 I have been appointed by the court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so  \n􀂅 I am acting in loco parentis and the patient is incapable of understanding the request  \n􀂅 I am the deceased person’s Personal Representative and attach confirmation of my appointment (Grant of Probate/Letters of Administration)  \n􀂅 I have written, and witnessed, consent from the deceased person’s Personal Representative and attach Proof of Appointment  \n􀂅 I have a claim arising from the person’s death (Please state details below)  \nSignature of applicant: ................................................ ............   Date:    \nYou are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.  \nSection 4: Proof of identity  \nEvidence  \nEvidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are:  \n\n|  | Type of applicant | Type of documentation |\n| --- | --- | --- |\n| A | An individual applying for his/her own records | One copy of identity required,\u003Cbr>e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. |\n| 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) |\n| C | Person with parental responsibility applying on behalf of a child | Copy of birth certificate of child & copy of correspondence addressed to person with parental responsibility relating to the patient |\n| 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) |\n\nAdditional notes  \nBefore returning this form, please ensure that you have:  \na) signed and dated this form  \nb) enclosed proof of your identity  \nc) enclosed doc","cbCaipi1fpIHi0vO","https://ap.wps.com/l/cbCaipi1fpIHi0vO","pdf",178159,"English","# Section 1: Patient details\n# Section 2: Record requested\n# Section 3: Details and declaration of applicant\n## Declaration\n# Section 4: Proof of identity","[{\"question\":\"Who can use this form to request access to health records under the GDPR?\",\"answer\":\"The form is for the patient, someone acting with written authorisation, a person with parental responsibility (with relevant conditions), a court-appointed manager, someone acting in loco parentis, or a personal representative of a deceased person, among other specified roles.\"},{\"question\":\"What information is required in Section 2 to identify the records requested?\",\"answer\":\"You must specify the treatment in respect of a relevant matter and provide records requested for the date range, the incident, or the condition, using the form’s guided prompts.\"},{\"question\":\"What proof of identity and supporting documents must be provided?\",\"answer\":\"The applicant must attach copies of required documentation based on the applicant type, such as identity documents and utility bills/medical cards for individuals, or court orders and evidence for representatives and agents.\"}]","APPLICATION FORM FOR ACCESS TO HEALTH RECORDS - Data Subject Access Request - Section 1 to 4 | PDF",1789832437]