Request Access to Medical Records (Subject Access Request)

If you would like to request access to your medical records, please submit this form.

We have 28 days to deliver on the request and we will attempt to contact you to confirm you are the one who made the submission. The 28 day period doesn’t start until we have received confirmation from you that the request has been done.

Hollybrook Medical Centre respects the rights of individuals to have copies of their information wherever possible.

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.

Subject Access Request
Who is accessing the medical records? *

Section 1 - Details of Patient's/Client's/Staff Member's Records to be Accessed

Please use this date format: DD/MM/YYYY
All responses we send will go to this email address

Section 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.

Please use format: DD/MM/YYYY
Please use format: DD/MM/YYYY
Please use format: DD/MM/YYYY
Please use format: DD/MM/YYYY
Please use format: DD/MM/YYYY
Please use format: DD/MM/YYYY

Section 3 - Details of Applicant

Section 4 - Authorisation to Release to Applicant

(To be completed by the patients/clients/staff member)

I, the patient/client/staff member whose records are to be accessed, hereby authorise the practice 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.

Section 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 select one option below: *

Please Note:

  • 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.
  • It may be necessary to provide evidence of identity (i.e. Driving Licence).
  • 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.
  • Under the terms of the Data Protection Act, requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
  • 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.
  • 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.