Access To Health Records Request

Access To Health Records Request


Record Requested

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).

Declaration of Applicant

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.
Please specify:
I have full parental responsibility for the patient and the patient is under the age of 18 and:

Proof of Identity

Method in which identity is confirmed:

Email copies of the documents; the practice will be in touch to confirm the practice email address.
Countersignature; this should only be completed in exceptional circumstances (e.g. in cases where the above cannot be provided)


Evidence of the patient’s and/or the patient’s representative identity will be required. Please email the practice with copies of the required documents. Examples of required documentation are listed below:


Type of applicant

Type of documentation


An individual applying for his/her

own records

One copy of identity required,

e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc.


Someone applying on behalf of an

individual (Representative)


One item showing proof of the patient’s identity and one item showing proof of the

representative’s identity (see examples in ‘A’ above)


Person with parental responsibility

applying on behalf of a child

Copy of birth certificate of child & copy of correspondence addressed to person with parental responsibility relating to the patient


Power of Attorney/Agent applying on behalf of an individual

Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)



This section is to be completed by someone (other than a member of your family) who
can vouch for your identity. This section may be completed if the Evidence section above cannot be fulfilled.
(Insert in what capacity, e.g. employee, client, patient, relative etc.)
Incomplete applications will not be processed.