Application Form for Access to Medical Records

Please use this form to apply for a copy of your medical records. You can choose to have a specific date range of your record, a copy of your entire record, or apply for a second copy of the information that has previously been provided by KAMP from a previous application.

Please think carefully before you request a copy of your records. Your record may be held in both paper form and electronically. We will have to copy both parts, and then a GP will have to review the entire record to check that there are no entries that contain personal data belonging to another individual. Where the GP finds such third party data, we will have to remove it from the copy that we are preparing for you.

Please help us to help you by making reasonable requests of our valuable time. In particular, do you need a copy of your entire record, or only a part of the record, for example covering a particular period? This form to request a copy enables you to ask for just a part of your record.

If you are human, leave this field blank.

Details of the Record to be accessed:

Patient Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

NHS Number

If Known

Full Address: *

Phone Number:

Email Address: *

Please choose one of the following options: *

I confirm that I am the above named patient

I am requesting this information on behalf of the above named patient

Details of the Third Party who wishes to make the request, as different from above.

Full Name: *

Phone Number:

Full Address:

Relationship to Patient: *

Please provide copies of relevant documentation confirming relationship to patient i.e. copy of birth certificate proving parental responsibility, Power of Attorney, Copy of the Will, Grant of Probate, etc

Please note – the information will be released to the Data Subject (Patient) only

Medical Records Options:

I wish to obtain a copy of my medical record: *

Option 1 - Part of the records between specific dates

Option 2 - The entire record

Option 3 - A second copy of which has previously been provided by KAMP

From (full date):

Please use this date format: DD/MM/YYYY.

To (full date):

Please use this date format: DD/MM/YYYY.

Date of Previous Request:

Please use this date format: DD/MM/YYYY.

Information that was provided:

Full Record

Specific Date Range

From (month and year):

To (month and year):

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 health records referred to above under the terms of the General Data Protection Regulation 2018.

I understand that copies under option 1 and 2 will be provided free of charge, unless the volume of material is considered excessive, in which case a charge may be levied, or in extreme cases, KAMP may legitimately refuse this request.

I understand that if charges are appropriate, KAMP will inform me of these in advance, and that I can then decide not to proceed, or to proceed in a different way that avoids the charge.

Signature: *

Date:

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Details of the Record to be accessed:

Details of the Third Party who wishes to make the request, as different from above.

Medical Records Options:

Declaration

KAMP Patient Participation Group