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.

Application Form for Access to Medical Records

Details of the Record to be accessed:

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

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

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:

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

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.