NHS App Access

Individual Proxy Access Form

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Proxy User Form - Accessing Your Own Medical Records

Please complete this form to request access to your medical records. Once submitted, a member of our team will contact you to verify your details and confirm that the request was made by you before processing your application.

Step 1 of 2

Name
Address
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 128 MB, Max. files: 3.

    Before we process your request

    Tick which apply
    I wish to have access to the following information:
    Select exactly 3 choices.
    I wish to have access to my health records online and understand and agree with the following statements:
    Select exactly 6 choices.
    DD slash MM slash YYYY
    Full name in CAPITAL LETTERS

    Carer Proxy Access Form

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    Proxy Access - Accessing Someone Else Records

    This form is used to request access to medical records for individuals such as your children, parents, or partners. To complete the request, you are required to provide two forms of identification: one for the person granting access to their medical records, and one for the individual who will be receiving access. You MUST provide valid forms of IDs with the application of this form. IDs should be provided for the individual giving access and the individual receiving access. If both IDs are not provided, we will reject the request. Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best of interest Section 1 of this form may be omitted Once submitted, a member of our team will contact you to verify your details and confirm that the request was made by you before processing your application.

    Step 1 of 2

    Section One – Patient’s Details

    The patient (This is the person whose records are being accessed)
    Name
    DD slash MM slash YYYY
    Address
    Drop files here or
    Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
      Please enter your full name

      Section 2 - Access Level and Type

      Please tick the access you would like to grant
      Please tick below to confirm you have read and understood the following:
      DD slash MM slash YYYY
      Full name in CAPITAL LETTERS
      DD slash MM slash YYYY
      Full name in CAPITAL LETTERS

      Section Three – Proxy User Details

      Person who will be granted access to the above patient’s records
      Name
      DD slash MM slash YYYY
      Address
      Drop files here or
      Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
        Consent
        Please tick below to confirm you have read and understood the following:
        Select exactly 7 choices.
        DD slash MM slash YYYY
        Full name in CAPITAL LETTERS
        DD slash MM slash YYYY
        Full name in CAPITAL LETTERS

        Additional Information

        Carers

        Chaperoning

        GDPR, Data Processing and Subject Access Request (SAR)

        Infection Control

        Long Term Conditions

        Summary Care Records

        Zero Tolerance Policy

        Non-NHS Services

        Patient Participation Group

        Responsibilities

        Talking Saves Lives

        Winter Health

        Community and Locality Services

        Complaints Policy