Subject Access Request

This form is to be completed when you require:

Copies of medical information from your medical record

A letter to be completed by the practice

PLEASE NOTE: A charge is made for letters requiring completion. This charge STARTS from £39.50.

IMPORTANT INFORMATION, PLEASE NOTE THE FOLLOWING: I understand that the GP/staff will supply all information considered to be relevant. I note the practice has one month to provide the information required but also understand this timescale may increase depending on the complexity of the requests. Requests for information to be supplied earlier are done purely at the discretion of the Park Surgery pending work pressure and may incur further charges equivalent to £10 per week for each week where the SAR has been provided earlier. However, please note:

WE CANNOT GUARANTEE ANY REQUEST FOR INFORMATION WILL BE COMPLETED BEFORE THE 30 DAY TIMESCALE.

I note that the GP/Staff will redact 'third party' information in the interests of the confidentiality of other persons. I further understand that I must bring photo I.D in order to collect this information. If I elect to send someone else to collect on my behalf, I must inform the practice of this when i am contacted and understand that this nominated person will also need to bring photo I.D. Further requests for the same information may be declined or liable to attract increased charges.

Last Updated: 06/04/2023

NAME

NAME *

Date of Birth *

Address *

Type of subject Access Request *

Letter Request (from £39.50)

Copy of Medical Records

FURTHER DETAILS REGARDING YOUR REQUEST. Letter requesting information - (PLEASE PROVIDE INFORMATION BELOW REGARDING YOUR REQUEST. PLEASE BE AS SPECIFIC AS POSSIBLE). Copy of medical information - (PLEASE PROVIDE INFORMATION BELOW REGARDING YOUR REQUEST. PLEASE BE AS SPECIFIC AS POSSIBLE I.E. DATE RANGE REQUIRED OR CONDITION MEDICAL RECORDS NEEDED FOR) *

In order for us to proceed with this subject access request we must satisfy ourselves that you have read all the information contained on the subject access request form and accept the terms, conditions and information contained within this Subject Access Request form including any charges and timescales. Please tick below to confirm you accept the terms mentioned and are happy to proceed. *

Yes No

WHAT HAPPENS NEXT: The practice will contact you when the Subject Access Request is complete and ready for collection or before this if further information is needed. Please note: The practice is willing to complete other Subject Access Requests such as the completion of forms. However, the form will need to be brought to the practice and a Subject Access Request Consent Document will need to be completed on site. Please feel free to contact the practice if further information needed.

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Subject Access Request

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