REQUEST FOR ACCESS TO RECORDS UNDER THE DATA PROTECTION ACT 1998

Your subject access rights

Subject to certain exemptions, you have a right under Section 7 of the Data Protection Act
1998 to be told whether East London NHS Foundation Trust holds any information about you
(your personal data), and a right to be provided with a copy of that personal data within a 40
day period. If you are requesting information about your health records the Trust will
endeavour to respond within 21 days. There may be a charge for accessing your records

If you wish to exercise those rights, please complete this form carefully and return to East
London NHS Foundation Trust at the address overleaf. You must include proof of your
identity and you must complete the declaration at Part E before the Trust is able to process
your request.

The Data Protection Act 1998 means that in some circumstances the Trust may decide not to
provide you with some personal data. An example of this is where information might identify
another person.

Part A. Your details

NHS no (only required for access to health records) .

Surname / family name

First name(s) .

Date of birth Male / Female .

Address (including postcode) .

..

Daytime telephone number ..

If your name and/or address was different for the period relating to the information you are
seeking please add details below

Previous surname(s) ..

Previous address(es) .

...

Applicable dates for information required .

Name & Address for reply if different to above (e.g insert solicitor details if response is to be
sent to a legal representative) .

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Part B. Proof of identity

The Trust must be satisfied you are who you say you are. To protect your identity your
application must be accompanied by photocopies of two different official documents that
between them provide sufficient information to prove your name, date of birth, current
address and signature e.g. driving licence, medical card, birth certificate, passport, utility bill.
Do not send original documents

Where information is requested by or is required to be supplied to a Third Party (such as a

solicitor) you must attach your consent to release your information to another party. The
consent form in Part F can be used for this purpose.

Part C. For access to a patients health care information

Personal data sought
Please provide as much detail as possible to enable the Trust to process your request. Give
full details of the episode(s) in which you are interested. If you only wish to access information
relating to a specific aspect of an episode of care, please specify in the any other information
section below.

Service(s) attended ..

Dates/date range attended

Name of clinician seen (if known)

RiO/hospital no (if known) .

Type of information required e.g discharge letter, records for 2010 etc

Any other information that may assist in locating & providing your information e.g episode of
care etc

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Provision of Information

Please note that our usual method of providing access to records is to post copies to your
stated address by recorded delivery. If you wish to access records by viewing the records at
a Trust location please tick the relevant box below. We will then contact you in order to
facilitate this.

Viewing records at a Trust Location

Collecting records from a Trust Location

Records to be sent by recorded delivery to your home address

Part D. For access to the personal information of staff, contractors, volunteers etc
Personal data sought
Please provide as much information as possible to help the Trust process your request.

Directorate & team where you worked / provided services ..

Date range of information required ..

Type of information required e.g HR record, PDP etc .

Any other information that may assist in locating & providing your information ..

Part E. Declaration

I declare that the information given in this application is correct to the best of my knowledge
and that I am entitled to apply for access to my records under the terms of the Data Protection
Act 1990

Full name of the applicant ..

Signature of the applicant ..

Date

Returning this form

Please return this form to:

The Healthcare Governance Coordinator

City & Hackney Centre for Mental Health
nd
2 Floor, Management Offices
Homerton Row
London
E9 6SR

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Part F (optional). Third party request form

If someone else is applying for information about you, on your behalf, the Trust needs your
permission to disclose the information to them. The following should also be completed and
returned to the Trust, together this Appendix.

Section 1. About the person applying for information about you (please use block
capitals and black ink)

Title: (Mr, Mrs, Dr, Rev etc) .

Surname / family name:

First name(s):

Address & postcode: .

Daytime telephone number: .

Section 2. Relationship to you. Please indicate relationship to you eg. Legal guardian,
representative

..

Section 3. Your consent to release information to the above person. In most

circumstances, the Trust is unable to release information to anyone other than the data
subject, unless that person gives explicit consent for the information to be released. By
completing the details below, you are giving consent for the above person to be supplied with
a copy of your records.
I consent to the above person being given access to, or a copy of, the personal information
East London NHS Foundation Trust holds about me:

Signature: ..

Date: