NHS App – Child / Career

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  Required
Date of Birth  Required
Address  Required
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
    Please enter your full name

    Section 2 - Access Level and Type

    Please tick the access you would like to grant  Required
    Please tick below to confirm you have read and understood the following:  Required
    Date  Required
    Full name in CAPITAL LETTERS
    Date  Required
    Full name in CAPITAL LETTERS

    Section Three – Proxy User Details

    Person who will be granted access to the above patient’s records
    Name  Required
    Date of Birth  Required
    Address  Required
    Drop files here or
    Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
      Consent  Required
      Please tick below to confirm you have read and understood the following:  Required
      Select exactly 7 choices.
      Date  Required
      Full name in CAPITAL LETTERS
      Date  Required
      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