Medical Records Access Request Form
for Adults without capacity

All patients have the right to ask for a copy of the medical records held by this GP practice. This is known as a Data Subject Access Request (DSAR).

Individuals who hold a registered Lasting Power of Attorney (LPA) for Health and Welfare, or a person appointed by the Court of Protection, may make a DSAR for a patient without capacity. In some instances, where a patient with documented loss of capacity has no LPA in place, we will consider a request from a family member, close friend or carer, in the best interests of the patient for a DSAR.

To keep their information safe, we will need to confirm your eligibility and identity before sharing their records. We usually respond within one month. If you need help completing this form or have any questions, please contact their practice.

Thanks for submitting!

This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request

Section 1: Your Details

Section 4: Purpose of your Request

Section 5: What Records are you Requesting?

Please be as specific as possible. This helps us provide the information quickly and reduces delays.

Understanding the purpose of your request helps us ensure you receive the correct information in the most helpful format.

Section 6: How Would you Like to Receive the Information?

Section 7: Proof of Eligibility and Identity

Section 8: Declaration

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 General Data Protection Regulations.

I am requesting: (Tick all that apply)

Section 2: Details of the Patient

Section 3: Relationship to the Patient

Orsborn House, 55 Terrace Rd, Birmingham, B19 1BP.

Medical Records Access Request Form
for Adults without capacity

This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request

Section 1: Your Details

Section 4: Purpose of your Request

Section 5: What Records are you Requesting?

Section 6: How Would you Like to Receive the Information?

Section 7: Proof of Eligibility and Identity

Section 8: Declaration

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 General Data Protection Regulations.

Section 2: Details of the Patient

Section 3: Relationship to the Patient

Accessibilty

Terms & Conditions

Patient Privacy Policy

Website Privacy Notice

Cookies

Freedom of Information

National Data Opt-Out (Type 2)

Medical Records Access Request Form for Adults without capacity

*This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request*

Section 1: Your Details

Section 4: Purpose of your Request

Section 5: What Records are you Requesting?

Section 6: How Would you Like to Receive the Information?

Section 7: Proof of Eligibility and Identity

Section 8: Declaration

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 General Data Protection Regulations.

Section 2: Details of the Patient

Section 3: Relationship to the Patient

Accessibilty

Terms & Conditions

Patient Privacy Policy

Website Privacy Notice

Cookies

Freedom of Information

National Data Opt-Out (Type 2)

Medical Records Access Request Form
for Adults without capacity

This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request