Subject Access Request form

GUIDANCE ON REQUESTING PERSONAL INFORMATION

The Trust is committed to being open and transparent about the way it uses your personal information. You can use this form to request a copy of the personal information the Trust holds about you. If you are unable to do this yourself someone can fill this form out on your behalf. The form can also be used by solicitors and other parties who have your permission to request this information on your behalf.

It is important that you provide a clear description of what information you require in order to enable it be to be located.

We will try and provide all information they have requested however there may be occasions where we are required to withhold information, for example of protect the identity of a third party.

Requests will be managed by the Legal Services Team however other departments in the Trust may be contacted to retrieve the information you have requested.

If you are requesting information relating to a deceased patient please used to Access to Health Records Request.

We aim to respond to all requests as soon as possible and within one month. It is possible to view the health record by arrangement with Legal Services or photocopies can be sent to you. Please state your preferred choice on the below form.

If you have any queries or would like further information about your rights for access to your health records, please contact us by:- Telephone: 01270 273917 E Mail: legal.services@mcht.nhs.uk

Section 1 – Please tell us the details below about you, or the person you are applying on behalf of

Patient’s surname: Required

Former surname (If applicable): Required

First name(s): Required

Title: Required

Date of birth: Required

NHS or hospital number (if known): Required

Current address: Required

Postcode: Required

Former address:

Postcode:

Daytime telephone: Required

Email address: Required

Section 2 – Personal details

What is your relationship to the Trust?

If you answered 'Other' to the above question, please specify here:

Your full name:

Address:

Postcode:

Daytime Telephone Number(s):

Email Address:

If you are NOT the patient, please select the appropriate option below to state your relationship with them.

Section 3 – What information is requested?

Please note that information will be posted to you by recorded delivery and will need a signature upon receipt. However, if the Royal Mail are unable to deliver to the address given and need to return the documentation to the Trust this will be returned by normal post (that is, not securely)

Please indicate which type(s) of records you wish to access? It is important that you provide a clear description of what information you require in order to enable it be to be located.

Please specify the date range of care and any other relevant details (eg condition / illness, area of care) - please note this will help to process the information required more efficiently

Please choose the appropriate option to indicate if you would like a copy of these records or just to view them

Section 4 – Confirming your identity and address

You can send printed copies or electronic copies.

Applying for yourself

If you are applying for yourself, we need to see:

➢ One document confirming your name, from Group A

➢ One document confirming your address, from Group B

Applying on behalf of someone else

If you are applying on behalf of someone else, we need to see:

➢ One document confirming your name, from Group A

➢ One document confirming the name of the person you are applying on behalf of, from Group A

➢ One document confirming your address, from Group B

➢ One document confirming the address of the person you are applying on behalf of from Group B

➢ All documents needed to show that you have the authority to access the records, from Group C

A. Documents that confirm your name / name of the person you are applying on behalf of:

• Full driving licence

• Passport

• Birth certificate

• Marriage certificate

• NHS Digital identity badge

B. Documents that confirm your address:

• Utility bill

• Bank statement

• Credit card statement

• Benefit book

• Pension book

C. Documents that confirm you are allowed to act on behalf of the person you are making the request for:

• Health and Welfare Lasting Power of Attorney

• Court of Protection Order appointing you as a personal deputy for the personal welfare of the Subject

• Full birth certificate of child

• Full certificate of adoption

• Parental responsibility order

• Signed declaration from the subject

Please upload Document A

Please upload Document B

Please upload Document C

In exercise of the right granted to me under the terms of the General Data Protection Regulations, I request that you provide me with the information I have requested. I confirm that this is all of the information to which I am requesting access. I also confirm that I am either the patient, or am acting on their behalf. I am aware that it is an offence to unlawfully obtain such information, e.g. by impersonating the patient. I certify that the information given in this form is true. I understand that it may be necessary for Mid Cheshire Hospitals NHS Foundation Trust to confirm my identity and it may be necessary to obtain more detailed information in order to confirm my identity and/or locate the correct information.

I agree

Please click here to agree to the declaration