Access to Medical Records form - Athena Medical Centre

APPLICATION FOR ACCESS TO MEDICAL RECORDS (SAR)

First Name

Surname

Date of Birth

Telephone number

Address

Postcode

NHS number (if known) Optional

Record requestedPlease tick the relevant boxes below. 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)

I am applying for access to view my records only

I am applying for an electronic copy of my medical record

I am applying for a printed copy of my medical record

Please specify what information you are requesting:

I would like a copy of records between specific dates only (please give dates below)

I would like a copy of records relating to a specific condition/specific incident only (please detail below)

I would like a copy of all my electronic records (held on computer)

I would like a copy of all my electronic and paper records since birth

Dates of records required or specific condition/incident Optional