Section 3 - What information is requested?
Please provide a clear description of the information you require. Where possible please describe:
Please note, the Trust holds a significant number of different types of data stored in various different records management systems. However the majority of patient information is retained within our Electronic Patient Record system (EPR) which went live in June 2025. Therefore, if no description of the data being requested is provided the Trust will provide any data it holds about the deceased that is recorded on the EPR.
Section 4 - Your relationship to the patient
I am the deceased patient’s personal representative – confirmation required. Please provide the following:
- Copy of will where you are named as Executor, or
- Grant of Probate, or
- Letters of Administration
A copy of the death certificate is also required. If you have a claim arising from the patient’s death, please give details of the exact nature of the claim below:
Section 5 - Confirming your identity and address
Please do not send any original documents. You can send printed copies or electronic copies. 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
➢ 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 deceased person you are making the request for:
- Grant of probate
- Letters of Administration
- Copy of death certificate is also required
Declaration
Option 1
I confirm that I am the deceased patient’s personal representative and have enclosed evidence of my status as Executor of the will or Administrator of the Estate together with two items of evidence that confirm my identity: (Proof of identity and evidence of being granted Power of the Executor of the Will or the Administrator of the deceased patient’s estate)
Option 2
I confirm that I have a claim arising out of the patient’s death and have enclosed 2 items of evidence that confirm my identity and documented evidence of my claim
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.