Request for Access to Personal Health and Social Care Records
General Data Protection Regulations / Access to Health Records (NI Order) 1993
Please complete application form in BLOCK CAPITALS and BLACK PEN and provide
identification as below.
I am requesting access to (please tick as appropriate) :-
1. my own personal record. Please complete sections
A, C, D & F
2. records belonging to another living individual. Please complete sections
A, B, C, D & F
3. records of a deceased person. Please complete sections
A, B, C, E & F
Please Note
Access to personal information is normally provided free of charge. However, PHA reserves
the right to charge a fee or to refuse to respond to a request that is manifestly unfounded
or excessive. Please ensure your request is as clear as possible. We may contact you
for further details.
Requests will normally be responded to within 30 days. However, please note that
the General Data Protection Regulation (GDPR) allows up to 90 days for providing a
response to complex requests.
For access to deceased patient healthcare records the Access to Health Records (NI) Order
1993 allows up to 40 days to respond to a request, or 21 days where the requested healthcare
records have been created within the last 40 days of the date of the request.
SECTION A – Details of the person the records / information relates to:
Surname:
First name(s)
Date of Birth:
Former name:
Current Address:
Post Code:
Tel. Number:
Any Previous address:
Hospital / Healthcare Number (if known):
1
SECTION B – Details of the person requesting the records (if different from section A above)
Surname:
Forename(s):
Applicant’s
Address:
Post Code:
Tel. Number:
Relationship to the named Patient / Client:
SECTION C –
Details of the record(s) you wish to access
Name of hospital, ward, clinic or
community service:
Type of Service Received:
Date(s) of treatment or service
provided (i.e. from / to)
Doctor / Health Professional / staff
seen (if known):
SECTION D – Authorisation and Proof of Identity.
In all cases a form of identification is required and must be provided with completed applications. (Acceptable forms of proof of identity are, for example, a copy of your passport, driving licence, Translink
Senior Citizen Smart Pass, electoral card, birth certificate or medical card).
Please also select 1, 2, 3 or 4 from the following options; (if 4, please also select further criteria)
1) I am the patient and enclose proof of my identity (copy or original ID documents)
2) I have parental responsibility however the child
is capable of understanding this request and
I attach their written consent allowing me to access their personal information on their behalf
3) I have parental responsibility and the child named above
is NOT capable of understanding
this request or consenting to the release of his/her records. I am acting in his/her best interests.
4) I am acting as an advocate on the patient’s / client’s behalf and
confirm that either:
The patient / client is capable of understanding this request and has asked that I act on
their behalf. Their written signed consent is enclosed along with a copy of ID for myself
and for the patient/client
The patient/client is NOT capable of understanding the request. I confirm that I am acting
on their behalf and in their best interests. I understand that capacity will be checked with
relevant health / social work professional(s) and records will only be disclosed if, in the
opinion of the relevant professional, it is in the patient’s / clients best interests. If approved,
I understand that any access provided will be limited to information that will meet the needs
of the patient/client.
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SECTION E –
Requesting Access to the Records of a Deceased Person –
The Access to Health Records (NI) Order 1993 (AHR) provides a legal right of access only to
HEALTHCARE RECORDS; however access is only granted to individuals who are the personal
representative of the deceased or individuals who may have a claim resulting from the death of the patient
and where evidence of entitlement is provided. In these cases only information relevant to the claim will be
considered for disclosure. A view may be sought from health care professionals.
Date of Patient / Client Death ______________________________
Please select from the following options;
1)
I am the personal representative of the deceased patient / service user and enclose documents
confirming my role as personal representative e.g. Grant of Probate / Letters of Administration. I also
enclose proof of my identity
2)
I am the personal representative of the deceased patient / service user and include evidence of this
from a solicitor or court office. I also enclose proof of my identity
3)
I have enclosed documentation from a solicitor detailing the claim I may have arising out of the patient
/ service user’s death and I also enclose proof of my identity
SECTION F – 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 records / information referred to
• I understand that applications received without the necessary ID / consent / legal
documentation will not be processed and will be returned
• I understand that the PHA is no longer responsible for the security and confidentiality of
any patient / service user records which have been supplied to me/copied.
Applicant’s signature:____________________________ Date:_____________________
Return the completed and signed subject access form along with supporting documents to:
Information Governance Team;
Public Health Agency
Towerhill
Armagh
BT61 9DR
3
Email: xxx.xxx@xxxxx.xxx
