Pemberton Surgery

01942 367199

Subject Access Request Form

This Practice respects the rights of individuals to have copies of their information wherever possible. This form is not a mandatory requirement however completing it will help us to process your request more efficiently.

Personal information collected from you by this form, is required to enable your request to be processed, this personal information will only be used in connection with the processing of this Subject Access Request.

Charges Payable: In accordance with legislation no fee will be charged for your request, unless the request is manifestly unfounded or excessive, particularly if it is repetitive. Before any further action is taken, we will contact you with details of our “reasonable administrative charges” in order to comply with your request.

  • 1. Details of Patient/Clients/Staff members records to be accessed (Please complete one form per person)

  • Date Format: DD slash MM slash YYYY
  • NHS number should be in the form nnn-nnn-nnnn for example: 123-456-7890
  • 2. Details of Records to be Accessed

    In order to locate the records you require please provide as much information as possible. Please list the department or services you have accessed that you require records from: i.e. PALs, complaints, continuing healthcare or Human resources etc (Continue on a separate sheet if required).
  • Click the + symbol to add more rows
    Records dated fromRecords dated toDepartment or services accessed 
  • Details of applicant (Complete if different to patients/clients/staff members details)

  • 4. Authorisation to release to applicant (to be completed by the patients/clients/staff member if not making their own request)

  • I hereby authorise the Pemberton Surgery to release any personal data they may hold relating to me to the above applicant and to whom I authorise to act on my behalf. (You will be required to sign the document to release the information)
  • Date Format: DD slash MM slash YYYY
  • 5. Declaration

  • I declare that information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act.
  • Please Note:

    • 1. If you are making an application on the behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order etc.
    • 2. It may be necessary to provide evidence of identity (i.e. Driving Licence).
    • 3. If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
    • 4. Under the terms of the Data Protection Act, Subject Access Requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
    • 5. If you are making a request under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client’s record 40 days immediately preceding the date of this request, otherwise requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.
    • 6. Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.
  • Date Format: DD slash MM slash YYYY
  • This field is for validation purposes and should be left unchanged.