Application to access to medical records

Application for access to medical records. Data Protection Act 1998 Subject Access Request

Please do not use this service for any urgent medical queries as this service is only monitored during practice working hours. Your question will be passed to an appropriate member of staff for a response. We aim to respond to all questions within two working days. If you do have an urgent medical query you should telephone the surgery or contact the out of hours service by calling 111. In an emergency please contact 999.

Your Details

Name *

I am the patient /parent or guardian (if under 16) or a personal representative of a deceased patient. I am eligible to apply for access. (A "personal representative" is an individual entitled to administer the estate of the deceased by virtue of a grant of probate (if a will was left) or by letter of administration if the patient died intestate (no will is left). This term is effectively synonymous with "administrator" or "executor" and it refers to a specific individual) *

What is the name of the patient if different from above

What are you requesting *

If extract, please provide dates

We will aim to process your request within 28 days. If this is not possible, we will contact to update you. I declare that the information above 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 Data Protection Act 1998 Signature: *

I understand that I am responsible for the storage, retention or onward distribution of these confidential documents. If I choose to share the contents of these with any third party, I understand that this is at my own risk. Please sign below on receipt of the records

Office use only Prior to releasing these documents. I have seen proof of ID (detail below) Staff member initials & stamped PATIENT COPY

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Page last reviewed: 08 April 2026

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Application to access to medical records

Application to access to medical records

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