Access to Personal Data and Information Requests

Use this form to manage your personal data.

You can use this form to request access to your personal data or ask for changes to how your data is used.

What you can request

You can use this form to:

Access your personal data
Request correction, also known as rectification, of your data
Request restriction of how your data is processed
Request deletion, also known as erasure, of your data in limited circumstances
Object to how your data is processed

Important: In most cases, healthcare organisations are required to retain patient records in line with the Public Records Act 1958.

This is necessary for public health and to ensure safe and appropriate care.

Restricting how your data is used

Your right to restrict processing only applies in certain situations:

There is a question about the accuracy of your data while it is being checked.
The processing is lawful, but you prefer restriction instead of deletion.
Your data is no longer needed for its original purpose.
You have objected to processing while it is being reviewed.

Requesting deletion of your data

Your right to have data erased only applies in limited circumstances:

Your data is no longer required for its original purpose.
You withdraw consent where consent was the legal basis.
Processing is based on legitimate interests and does not override your rights.
Your data is used for direct marketing and you object.
Your data has been processed unlawfully.
There is a legal obligation to erase the data.
The data relates to certain digital services provided to a child.

Objecting to data processing

You have the right to object to certain types of data processing.

Type of processing	Your rights
Direct marketing, including profiling	You have an absolute right to object.
Processing based on legitimate or public interest	You can object, but processing may continue if there are overriding legitimate grounds.
Scientific, historical or statistical research	You can object unless processing is necessary for public interest tasks.

Additional information

You do not have to use this form, but it helps us process your request more efficiently.
You can complete this form on behalf of someone else. Proof of authority may be required.
There is usually no charge for accessing your records.
A reasonable fee may apply for excessive or repeated requests.

Section 1: Details of the individual for whom the request relates

Title

Surname

Forename(s)

Address including Post Code

Date of Birth

For example, 15 3 1984

Day

Month

Year

NHS Number (if known)

Contact Telephone Number

In order, to protect your information, we are unable to respond to a request unless we have confirmed your identity. Please provide one form of identification and one proof of address. If you are posting copies to us, please ensure these are appropriate certified, alternatively please attend the practice with original documents (acceptable documents listed below):

Documents that can be used as proof of Identity:

1. Current signed passport 2. Residence permit issued by the Home Office 3. EU or Swiss national identity photo-card 4. Valid UK photo-card driving licence (full or provisional) 5. Valid armed or police forces photographic identity card 6. Photographic disabled blue badge 7. Citizen card

Please upload the relevant document as proof of identity

Documents that can be used as proof of current address (must be dated in the last six months):

1. Recent original utility bill (i.e. gas, electric, water, telephone - not mobile) 2. Hospital Appointment Letter 3. Council tax bill (valid for current year) 4. Bank, building society or credit union statement or passbook 5. Recent original mortgage statement from recognised lender 6. Current council/housing association rent book or tenancy agreement 7. Notification letter from Department for Work and Pensions / HM Revenue and Customs confirming your right to benefit or state pension

Please upload the relevant document as proof of address

Section 2: Whose personal data are you requesting?

Please select which of the following applies

I am the patient named in section 1 (please proceed to section 3)
I have a signed letter of authority to make this request
I have parental responsibility for the patient who is under the age of 16 (please enclose a copy of proof of parental responsibility i.e. parental responsibility order issued by the Court or a copy of the Childs full birth certificate) - Please note that you do not have an automatic right to your child’s data and decisions will be made on the relevance of release of data to you. In the UK a child aged 13 years or older in most circumstances will be required to consent to the release of their data
I have been appointed through a Lasting Power of Attorney to act on behalf of the patient (N.B. proof must be enclosed before the application can be processed i.e. a copy of the sealed document)
Other Reasons (please outline)

Other reason

If you are not requesting access to your own personal data, please provide the following information about you:

Full Name

Address to include postcode

Date of Birth

For example, 15 3 1984

Day

Month

Year

Contact Telephone Number

Relationship to individual for whom you are requesting data:

PLEASE NOTE: If you are not requesting access to your own personal data, we are unable to respond to your request until we also receive the following:

• Satisfactory confirmation of the identity of the person on whose behalf you are making this request. Please provide details outlined in section one.

• A copy of your legal authority to make this request. This may be a signed letter of authority, a power of attorney document or other legal document confirming you are their legal representative

Section 3: What data are you requesting?

Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification, or objection. Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.

Please tick the type of request that best matches what you need:

Declaration

I declare that the information given in this form is correct to the best of my knowledge and that I am entitled to apply for access to the records referred to under the terms of the UK General Data Protection Regulation (UK GDPR) 2016, Access to Records Act 1990 or the Mental Capacity Act 2005.

PATIENT ACKNOWLEDGMENT AND CONSENT FOR RECEIPT OF SENSITIVE DOCUMENTS

I hereby request and consent to receive documents from the medical practice that may contain sensitive personal and/or medical information relating to my healthcare. I understand and acknowledge that:

The documents provided to me may contain confidential and sensitive personal data, including medical information.

Upon receipt of these documents, I am responsible for their safekeeping and security.

I will review the documents carefully before sharing, forwarding, copying, uploading, or otherwise distributing them to any third party.

If I choose to disclose these documents to any third party, I do so at my own discretion and responsibility.

The medical practice is not responsible for any unauthorised access, disclosure, loss, or misuse of the documents after they have been delivered to me in accordance with my request.

I understand the risks associated with transmitting, storing, or sharing documents electronically and accept these risks.

I confirm that the contact details or delivery method I have provided are accurate and belong to me or are authorised by me for receipt of these documents.

Please check the information you have provided. By signing below, I confirm that I have read and understood this acknowledgment and consent and agree to the above terms.

Full name of Applicant

If you need to clear your signature from the box above and start it again, click here.

Signature of Applicant

Date

For example, 15 3 1984

Day

Month

Year