Medical Records Access Request Form
(Child’s/Young Person (Aged 11 to 16 Years)

Children aged 11-16 years and authorised individuals may make a Data Subject Access Request (DSAR) to receive information included in their medical records. This form enables requests for a DSAR to be made, explains who may do this, and the process they need to follow.

Under the age of 11, parents/legal guardians may decide who has access to their child’s medical information under a DSAR. Beyond the age of 16, a person is legally presumed to have capacity to manage their own records and request a DSAR.

Who Can Make a Data Subject Access Request (DSAR) for a Child/Young person?

A child dependent on age and competency
Parents with parental responsibility
Guardians and court appointed individuals
Authorised third parties: Individuals with written permission from a competent child or from someone with parental responsibility (for example solicitors).

Key Considerations and Age Milestones for Children

11-13 Years: Parent’s consent is usually sought if a child or other authorised individual applies for access to a DSAR
13-16: A GP will assess the competency of a young person before allowing them or other authorised individuals access to a DSAR. If a young person is considered competent, parent/legal guardian consent is not required.

First Name

Last Name

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

Date of Birth

Phone Number

Address

Email Address

What is the main purpose of your request? (Tick all that apply) Required

Personal perusal / general understanding

To share with another healthcare provider for direct patient care

To support a medico‑legal claim against this practice or against another party

To support an application or appeal for state benefits (e.g., PIP, UC)

To apply for an insurance policy

To make a claim on an existing insurance policy

For research (personal or academic)

Other (Please use this space to briefly explain what you need and why)

Section 2: Details of the Child/ Young Person

Section 3: The Relationship With the Child/ Young Person

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

Sources of information to include: (Tick only one) Required

Provide only the information held within the principal electronic health record system or

Provide all information held across systems used by the practice. This would include any significant events investigations regarding your child's care.

Your Signature

Additonal Documents

Upload any supporting documents

Upload supported file (Max 15MB)

Postcode

Section 5: What Records are you Requesting?

Please tick one option: Required

By secure email transfer

Collection at the practice

Section 7: Proof of Identity / Legal Eligibility

To keep the medical information of the child/ young person safe, we need to confirm the identity/legal eligibility for accessing these records. Please tick one option below to show which type of proof you will provide.

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.

Name

Date Signed

Records from a specific date range

Records related to a specific condition:

From

I am requesting: (Tick all that apply)

Title

First Name

Last Name

Date of Birth

Address

Postcode

A full copy of all medical records

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

Records relating to a specific event / illness / episode of care: (please describe below)

Title

Are you a young person, aged 13-16, and requesting your information?

(IF YOU ARE THE YOUNG PERSON, you do not need to complete section 2 and 3)

Are you a child aged 11-13?

(If you are, you will need parental consent to obtain these, and do not need to complete section 2 and 3)

I am the young person and I am aged between 13-16 years of age

I have full parental responsibility/ I am the guardian or court-appointed individual for the child and they are under the age of 13

I have full parental responsibility/ I am the guardians or court-appointed individual for the patient and the patient is between the age 13 to 16 and

I am an authorised third parties with written permission from a young person older than age 13, or from someone with parental responsibility

If >13 years old, has consented to my making this request, or

Cannot consent because they are unable to understand the request

Section 4: Purpose of your Request

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

Young person aged 13-16 years

If you are the young person, aged between 13-16 years of age: Photo ID if available, or 3 verbal identifiers of identity (Date of birth, address, telephone number)

If you have full parental responsibility and the young person has consented to this request: written consent, proof that the young person lives with you (this may be available on your young person’s electronic medical records), and your photo ID

If you are a legal guardian, or have a court order and the young person has consented to this request: written consent, proof of guardianship or court order, and your photo ID

If you have full parental responsibility, you are a legal guardian, or have a court order, and the young person is unable to consent, you will need: proof that the young person lives with you (this may be available on the young person’s electronic medical records), proof of guardianship or court order and your photo ID

You are an authorised third parties with written permission from a competent young person (usually a solicitor): written permission

Child between 11-13 years, not making the request for themselves

If you are a parent, with full parental responsibility: Photo ID and proof that the child lives with you (this may be available on your child’s electronic medical records)

If you are a guardian or court-appointed individual: a court order

I am an authorised third party with written permission from a parent/legal guardian: written permission

Child between 11-13 years, making the request for themselves

If you are the child, aged between 11-13 years: Photo ID if available, or 3 verbal identifiers of identity (Date of birth, address, telephone number), and written consent of parent/legal guardian

Medical Records Access Request Form
(Child’s/Young Person (Aged 11 to 16 Years)

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 2: Details of the Child/ Young Person

Section 3: The Relationship With the Child/ Young Person

Section 5: What Records are you Requesting?

Section 7: Proof of Identity / Legal Eligibility

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 6: How Would you Like to Receive the Information?

Section 4: Purpose of your Request

Accessibilty

Terms & Conditions

Patient Privacy Policy

Website Privacy Notice

Cookies

Freedom of Information

National Data Opt-Out (Type 2)

Medical Records Access Request Form (Child’s/Young Person (Aged 11 to 16 Years)

*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 2: Details of the Child/ Young Person

Section 3: The Relationship With the Child/ Young Person

Section 5: What Records are you Requesting?

Section 7: Proof of Identity / Legal Eligibility

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 6: How Would you Like to Receive the Information?

Section 4: Purpose of your Request

Accessibilty

Terms & Conditions

Patient Privacy Policy

Website Privacy Notice

Cookies

Freedom of Information

National Data Opt-Out (Type 2)

Medical Records Access Request Form
(Child’s/Young Person (Aged 11 to 16 Years)

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