SUBJECT ACCESS REQUEST FORM
APPLICATION FOR ACCESS TO MEDICAL RECORDS

Details of the Record to be Accessed (the data subject):
Patient Surname		
Forename(s)		
Date of Birth		

Details of the Person who wishes to access the records, if different to above:
Surname		
Forename(s)		
Address		
Telephone Number		
Relationship to Patient		

Tick whichever of the following statements apply:
	I am the patient
	The patient is under age sixteen; I am the patient’s parent or legal guardian and have parental responsibility
	I am the deceased patient’s Personal Representative and attach confirmation of my appointment
	I have a claim arising from the patient’s death and wish to access information relevant to my claim on the following grounds: ....……………………………………………………….………………………………………... ....................…………………………………………………………………………………………………………….
	I have been asked to act on behalf of the patient and attach their signed, written authorisation.

Please provide the following:
•	Photo ID: Driving licence or, Passport or birth certificate of the data subject.
•	Proof of address, e.g. a utility bill (no longer than 3 months old) of the data subject.
And, if you are acting on behalf of the patient e.g. solicitor:
•	A signed letter of authorisation from the data subject consenting that the solicitor can act on their behalf OR;
•	Lasting Power Attorney.

Please give details as to the information you would like to review:
(Include the date range(s) for the information required)

………………………………………... ....................………………………………………………………...

………………………………………... ....................………………………………………………………...

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 Data Protection Act 2018.

YOUR SIGNATURE……………………………….………….. DATE ………………………..

Please return this completed Subject Access Request (SAR) Form and any requested documentation to: East Finchley Medical Practice, 39 Baronsmere Road, N2 9QD

NOTES:
The Practice will normally respond to a Subject Access Request within one calendar month of receipt. This period will not commence until the practice is satisfied as to the identity and authority of the applicant.
The Practice may seek further information from the applicant as to the specific information requested. Any request for clarification will suspend the one calendar month period until the required information is received.

For practice use only
Please check patient’s ID and indicate below. Copies DO NOT need to be taken
EMIS Number:	NHS number:	
Identity verified by:	Date:	Documents seen (e.g. passport, driving license, utility bill):
1.	 
2.