Application for Access to Medical Records (SAR) In accordance with the UK General Data Protection Regulation (UK GDPR). Section 1: Patient detailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date of birth Day Month Year Contact NumberAddress Street Address Address Line 2 City Postcode NHS number (if known) Optional Email Enter Email Confirm Email Section 2: Record requestedWhat are you applying for? I am applying for full online access to the records I am applying for an electronic copy of the medical record to be sent to me by e-mail Please note that the practice uses a software called iGPR to support processing of medical record access requests: iGPR Technologies Limited (“iGPR”), is a processor that assists us with responding to report requests relating to your patient data, such as subject access requests that you submit to us (or that someone acting on your behalf submits to us) and report requests that insurers submit to us under the Access to Medical Records Act 1988 in relation to a life insurance policy that you hold or that you are applying for. iGPR manages the reporting process for us by reviewing and responding to requests in accordance with our instructions and all applicable laws, including UK data protection laws. The instructions we issue to iGPR include general instructions on responding to requests and specific instructions on issues that will require further consultation with the GP responsible for your care.Please specify what information you are requesting: I would like a copy of records between specific dates only I would like a copy of records relating to a specific condition/specific incident only I would like a copy of all my electronic records (held on computer) I would like a copy of all my electronic and paper records since birth The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)Please give datesPlease give detailsSection 3: Details of ApplicantWho are you applying for? I am applying for access to my own medical record I am applying for access another person’s record Please complete if you are requesting access on behalf of the above-named patientPerson's Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Person's Address Street Address Address Line 2 City Postcode Person's Contact NumberYour relationship to patient Reason for access: I have been asked to act by the patient and I have enclosed written consent from the patient to act on their behalf. I have full parental responsibility for the patient and the patient is under the age of 16 and has consented to my making this request, or is incapable of understanding the request I have been appointed by the Court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so I am acting in loco parentis and the patient is incapable of understanding the request I am the deceased person’s personal representative and attach confirmation of my appointment (copy of will or grant of probate or letters of administration) I have written, and witnessed, consent from the deceased person’s personal representative and attach Proof of Appointment I have a claim arising from the person’s death (please state details below) Please upload the specified document Drop files here or Select files Max. file size: 50 MB. Please specifySection 4: DeclarationI 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 health records referred to above under the terms of the UK Data Protection Act 2018. You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.SignatureConsent I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical recordsPatient's SignatureSection 5: Proof of identityPatients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Upload two forms of ID Drop files here or Select files Max. file size: 50 MB. Section 6: Consent for childrenIf a child aged 13 or over has “sufficient understanding and intelligence to enable them to understand fully what is proposed” (known as Gillick Competence), then they will be competent to give consent for themselves. Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves. If the child is under 16 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf.