Application for Access to Health Records

Please read the Information prior to completing this form.
Please ensure all the fields marked* are filled in correctly.

Particulars of Person whose information is required

 
 
 
   
   
 

Which of the following do you require (please tick)?

Please note that we may not have direct access to some contracted or shared services such as Gastroenterology, Audiology, Dental or IAPT. If you have attended any of these services and require the notes, please list the services here.


Relationship to Patient (for patients who are living):

Please tick to confirm status of relationship to Patient

(if the subject is unable to provide written authorisation, Please enclose a photocopy of proof of power of attorney / Court Order)

I have proof of parental responsibility (required for any individual aged 12 or under or for those not able to provide consent)

(i.e. Parental responsibility order issued by the court or a Photocopy of Child Full Birth Certificate)


If applying for a deceased patient’s records:

Please provide one or more of the following proofs and indicate below which you have:

All proof documents should be sent to SAR.WhittHealth@nhs.net. Should you wish to send us a secure encrypted message for this purpose, you can do this by registering for a free Egress account here

I have read this form and authorise a subject access request to be carried out.