DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST

Transcription

1 DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST APPLICATION FOR SUBJECT ACCESS TO PERSONAL DATA Data Protection Act 1998 & Access to Health Records 1990 To include General Data Protection Regulation (GDPR) May 2018 PLEASE ENSURE THAT THIS FORM IS COMPLETED FULLY AND IN BLOCK CAPITALS 1 - Data Subject Title Date of Birth Please Circle Mr Mrs Miss Ms Other (please state): Forename Previous Address Any Relevant Previous Address Home Phone Number Mobile Phone Number address 2a - The Applicant Please tick. I am both the Data Subject and the Applicant. Continue to Part 3. The Data Subject is living and I am acting on their behalf. Complete this section and continue to Part 2b. The Data Subject is deceased and I wish to gain access to their records. Complete this section and continue to Part 2c. Title Address Please circle Mr Mrs Miss Ms Other (please state): Forename Home Phone Number Mobile Phone Number Address Application Form May 2018 Page 1

2 2b - The Applicant For accessing a living person s records Please tick. I have parental responsibility for the Data Subject who is under the age of 16 and is incapable of understanding this application. The Data Subject is aged over 16 but is incapable of understanding this application. I am making this application as I believe it to be in the Data Subject s best interests. I have been asked to act by the Data Subject Please provide proof that you are legally authorised to act on the Data Subject s behalf in the form of: Signed letter of authority from Data Subject authorising Applicant to act on their behalf Evidence of parental responsibility Lasting Power of Attorney Other please provide details 2c - The Applicant For accessing a deceased person s records Please tick, and if requested, enclose the applicable documentation. I am named as contact by the deceased person within the health record for the period specified in Part 3. I am the Executor of the Will. I enclose a copy of the said Will and I sign below as confirmation that to the best of my knowledge, information and belief this is the last Will and Testament of the deceased. (Alternatively, please provide a copy of the Grant of Probate). Signature: I am a person granted Letters of Administration by the Probate Registry and enclose documented proof of the Grant. I am a person with a financial claim arising out of the person s death and wish to access information relevant to my claim on the grounds that (please complete) Please continue on a separate page if required Application Form May 2018 Page 2

3 3 What information do you require? (see guidance) We ask that you provide as much information as possible. Please inform us if you only wish to have access to specific information it will help us to deal with your enquiry much more promptly. Please tick Copies of my health records as detailed in Section 4 (Hospital/NHS Number..) if available. Copy images (e.g. x-rays/ct scans) on CD and their accompanying reports. I wish to have an appointment to view my records. Please be aware these viewings are limited to a one hour appointment. You will be contacted by a member of the team to arrange a mutually convenient appointment. I require copies of my staff personnel file (Personnel Number.....) if available. I require copies of my Patient Advice and Liaison Service File (PALs) and/or Complaint File. Other (please provide details) Application Form May 2018 Page 3

4 4 - Details of records/information you require (see guidance notes) Dates Required Details Consultant (if applicable) From To Dates Required Details Consultant (if applicable) From To Dates Required From To Other Miscellaneous Information Application Form May 2018 Page 4

5 5 - Proof of Identity of the Applicant (see guidance) It is essential that we obtain adequate proof of identification which permits us to establish the Applicant s right of access under the Data Protection Act. You need to complete one of the following options: a) Enclose photocopies of two forms of identification at least one must include a photograph (e.g. passport, driver s license) I enclose two photocopies of formal identification and confirm they are true copies of the originals. Signed: b) Have an independent professional person sign the form as indicated below (e.g. lawyer, police officer, GP, employer or a person of similar social standing who has known you personally a relative should not countersign) I certify that I am (name): Of (address): and that I have known the applicant for years as a and I have witnessed the applicant sign this application. Signed: Contact Number: Please provide a contact number in case we have any queries. 6 - Declaration I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the data/health records referred to under the terms of the Data Protection Act 1998 and Access to Health Records Act Signed: Please return the completed form to: Information Access Office Records Management Services Derby Teaching Hospitals NHS Foundation Trust Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Alternatively your application to: dhft.informationaccess@nhs.net Contact: Office Hours Mon-Friday 08:00-16:00 Application Form May 2018 Page 5