Subject Access Request (SAR)

The General Data Protection Regulations (GDPR & DPA 2018) provides you, the data subject, with a right to receive a copy of the data/information we hold about you or to authorise someone to request your information on your behalf. Please complete this form to help us to safely action your request and ensure you receive the information you require.

It is our Practice Policy for medical records to be collected, should you be unable to do this please contact the Practice. Your request will be processed within one calendar month upon receipt of a fully completed form.

Please note that you will need to provide proof of your identity upon collection of your information.

Please be aware that the Practice now uses an approved third-party processor “iGPR” to safely and securely action some subject access requests. Details on iGPR can be found on the Practice website but should you have any questions regarding iGPR please contact the Practice.

Details of the person who the data concerns

First

Last

data Telephone unclear.

Date of Birth *

NHS Number

If known

Mobile Number

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Signature *

If appropriate, details of the third party representative authorised to make the request on behalf of the person named above:

Name

First

Last

Date of Birth

Telephone number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relationship to person named above

Authority to make this request:

Consent (please provide appropriate evidence)
Parental responsibility (child under 13)
Lasting Power of Attorney (Health & Welfare)

Signature

Details of information required:

Where ‘other’ is selected please be as specific as possible. We may need to speak with you to confirm the request if this is unclear. *

Entire medical history held since birth (Please be aware that this includes both manual and electronic records, consultations, medications, documents etc)
Patient profile only (no documents) 3 months
Patient profile only (no documents) 6 months
Patient profile only (no documents) 12 months
Patient profile only (no documents) other - please specify below
Medication history
Allergies

Other