DETAILS OF APPLICANT:
Surname
Forename(s)
Email address
Address
Telephone number
May we leave an answer phone message? Yes No
Please tick the appropriate boxes: I am the patient and over the age of 16 years. I am the person who has legal responsibility for the patient, who is under the age of 14. The patient is over 14 years of age and under 16 years of age, has consented to my making this request and has authorised my application. I am acting on behalf of the patient (aged over 16). Please be advised that you will need to provide proof that you have power of attorney or that you are the legal representative. I am the deceased patient’s personal representative and attach either letters of administration or a grant of probate. I have a claim arising from the patient’s death and wish to access information relevant to my claim on the grounds that:
Name of Patient
Signature
Unless you have requested paper copies, records will be sent out to you via an delivery system. The password to open this document will be emailed to you.
DETAILS OF PATIENT:
Surname
Forename(s)
Address
Date of birth
Title
Gender
NHS number
Hospital number
If the name and / or address were different from above during the time period(s) to which the application relates - please give details below:
To help the NHS save time and resources it would be helpful if you could provide details below, informing us of the parts of the health records you require, along with details which you may feel have relevance i.e. dates, consultant name, location, written diagnosis and reports etc.
Please use the space below to document, continuing on another page if necessary
Which records are you requesting? (Please tick the applicable boxes) WWL Hospital Services (Royal Albert Edward Infirmary, Leigh, Wrightington, Thomas Linacre, Boston House) WWL Community Services (Walk In Centre, District Nurse, Mental Health etc.) Both
WWL Services:
WWL HOSPITAL / CLINIC CONTACTS (Please provide as much information as possible)
WWL Community:
WWL COMMUNITY CONTACTS (please provide as much information as possible)
Do you wish to arrange an appointment to view the original records in the presence of a member of staff? Please note this will be a member of the Information Governance Team who is not medically trained. Yes No
I would prefer to receive the records as paper copies. Yes No
In order that we can process your application request efficiently would you please advise us if this application is in connection with an ongoing complaint against the Trust? Yes No
If yes, please enter your complaint reference number below:
Declaration:
I declare that the information supplied above is correct to the best of my knowledge and that I am entitled to apply for access to the above record(s) under the terms of the Data Protection Act 2018. I enclose two forms of identification one of which must be a photocopy of photographic identification; the other must be a utility bill:
We cannot process your application without proof of identity.
Signature
Date
Please return this form to:-
Access to Health Records Department
