*This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request*
Section 1: patient Details
Section 2: Which parts of your record are you requesting?
The more specific you can be, the easier it is for us to quickly provide you with the records requested.
Section 3: Details and declaration of applicant
Please enter details of the applicant if different from section 1
Declaration
I declare that the information given by me is correct to the best of my knowledgeand that I am entitled to apply for access to the health records referred to above under the terms of the GDPR.
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.
Section 4: Proof of Identity
We would prefer photo ID such as: a valid passport, a driving license, biometric residence permit.
If you do not have any photo ID we can accept instead the following:
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A UK birth certificate
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Marriage or civil partnership certificate (UK and Channel Islands)
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Adoption certificate
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HM Forces ID card
4A. Evidence
We are required to make a reasonable attempt to identify that you are entitled to request a subject access request. If you are unable to provide us with any evidence of your identity, we may ask you further questions to confirm this.
Additional notes
Before returning this form, please ensure that you have:
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Signed this form
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Enclosed the proof of your identity
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Enclosed documentation to support your request (if applying for another person’s records)
Incomplete applications will be returned; therefore please ensure you have the correct documentation before submitting the form.
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