Online Access to GP Services Request

Guidance Notes - Please read before completing this form

If a child aged 13 or over has sufficient understanding and intelligence to enable him/her to understand fully what is proposed (known as Gillick Competence), then s/he will be competent to give consent for him/herself but may wish a parent to countersign as well.

Who is requiring access? *

Patients requiring access to their own record

Proxy access to health records where patient has capacity

Proxy access to health records where patient does not have capacity

Parents requiring access to their child's (age 13-17) record

Section 1: Patient Details

Please specify: *

Surname: *

Previous Surname:

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode: *

NHS number (if known):

Hospital number (if known):

Section 2: Record Requested

I wish to have access to the following online services:

Please tick all that apply:

Booking appointments

Requesting repeat prescriptions

Access to my medical records

I wish to access my medical record online and both understand and agree with each of the following statements: *

I have read and understood the Online Access for Patients - Important Information provided by the organisation.

I will be responsible for the security of the information that I see or download.

If I chose to share my information with anyone else, this is at my own risk.

I will contact the organisation as soon as possible if I suspect that my account has been accessed by someone without my agreement.

If I see information in my record that is not about me or is inaccurate, I will contact the organisation as soon as possible.

Patient Signature: *

Date:

Is the patient aged 13-17 and wishes a parent/guardian to countersign? *

Yes

No

Signature of Parent/Guardian: *

Date:

Section 3: Consent to proxy access to GP Online Services (if patient has capacity)

I (the patient) give permission to my GP practice to give the following person/people proxy access to the online services as indicated below in Section 5.

I (the patient) reserve the right to reverse any decision I make in granting proxy access at any time.

I (the patient) understand the risks of allowing someone else to have access to my health records.

I (the patient) have read and understand the information leaflet provided by the organisation.

Patient Signature: *

Date:

I/We (the proxy) wish to have access to the health records on behalf of the named patient

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

Reason for access:

I/We have been asked to act by the patient.

I/We have full parental responsibility for the patient and the patient is under the age of 18

I/We have full parental responsibility for the patient and the patient is under the age of 18 and: *

Has consented to my making this request

Is incapable of understanding the request

Section 4: Consent to proxy access to GP Online Services (if patient does not have capacity)

I/We (the proxy) wish to have access to the health records on behalf of the named patient.

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

Reason for access:

I/We have been appointed by the Court to manage the patient's affairs and attach a certified copy of the court order appointing me to do so.

I am/We are acting in loco parentis and the patient is incapable of understanding the request.

I am/We are the deceased person's personal representative and attach confirmation of my/our appointment (grant of probate/letters of administration).

I/We have written and witnessed consent from the deceased person's personal representative and attach Proof of Appointment.

I/We have a claim arising from the person's death.

Please provide details of the claim arising from the person's death: *

Section 5: Proxy access online services available

I/We (the proxy) wish to have access to the following online services (please tick all that apply):

Please tick all that apply:

Booking appointments

Requesting repeat prescriptions

Access to the patients medical records

Section 6: Proxy Declaration

I/We (the proxy) wish to access to the medical record online of the above patient and I/we understand and agree with each statement: *

I/we have read and understood the Online Access for Patients - Important Information provided by the practice and agreed that I will treat the patient information as confidential.

I/we will be responsible for the security of the information I/we see or download.

I/we will contact the Practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement.

If I/we see any information in the record that is not about the patient, or is inaccurate, I/we will contact the Practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 2018.

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

Your signature(s): *

Representative 1

Date:

Your signature(s):

Representative 2

Date:

Section 7: Proof of Identity

Under the Data Protection Act 2018, you do not have to give a reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up.

Please speak to reception if you are unable to provide this.

Supporting Documentation

If applicable, please attach any documentation to support your request:

Maximum upload size: 67.11MB

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Guidance Notes - Please read before completing this form

Section 1: Patient Details

Section 2: Record Requested

Section 3: Consent to proxy access to GP Online Services (if patient has capacity)

Section 4: Consent to proxy access to GP Online Services (if patient does not have capacity)

Section 5: Proxy access online services available

Section 6: Proxy Declaration

Section 7: Proof of Identity

Supporting Documentation

Self Help