Form 2

PATIENT AUTHORITY CONSENT FORM

Access to Health Records under the new legislation

If you are the patient, please complete part 1 only. If you are NOT the patient but are
applying on behalf of the patient, please complete Parts 1 and 2.

Part 1- Patient details

1. Full name (including former name(s)) Mr/Mrs/Miss/Ms…………………………………………..

(please print all details and use dark
ink) Former Name(s)………………………………………….

2. Date of Birth: ……………………………………………………………..

3. NHS number (if known) ……………………………………………………………..

4. Current address: ……………………………………………………………..

……………………………………………………………..

……………………………………………………………..

Tel number (incl. area

(optional) code)………………………………………………………

5. Former addresses (if applicable) ……………………………………………….............

(use separate sheet if necessary)
…………………………………………………………

6. I am applying for access to view my health records/I am applying for copies of my health records
(Delete as appropriate)

Important Information

7. Under the new legislation you do not have to give a reason for applying for access to your health
records. However, to help us save time and resources, if you wish, it would be helpful if you
could use the space provided below to inform us of certain periods and parts of your health
record you may require. This may include specific dates, along with details which you may feel
have relevance, i.e. consultant name and location and parts of the records you require, for
example, written diagnosis or reports. Please confirm the main hospital you visited and clarify the
department/clinic you attended. You may use a separate sheet of paper if necessary.

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 Below is an example of the type of information which would be helpful. Please complete in
the space provided.

Example:

1st March 2001 – 31st March 2005 All correspondence and consultant reports to my GP concerning
back pain in this period.

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

8. Identification (please only send photocopies) :

We cannot process your application without proof of identity.

Please indicate which of the following identification documents are enclosed

Driving Licence OR Passport/Birth Certificate

And additional proof of address e.g. utility bill

9. I am applying to access my health records under the new legislation for health records held at:

Manchester Foundation Trust

Main Hospital……………………………………………………………………………………………

Department/ward/Clinic ………………………………………………………………………………

10. Signed………………………………………………… Date:………………………………………..

If you are not the patient but are applying on behalf of the patient, please complete Part 2.

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PART 2

Relative/Guardian/Agent acting on behalf of the patient

If you are not the patient please state your full name and relationship to the patient:

……………………………………………………………………………………………………………………….

Your Address:

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Please state briefly the reason why this application is being made by you

……………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Your Signature…………………………………………………………

Name in Capitals……………………………………………………….

We cannot process your application without proof of identity.

Please indicate which of the following identification documents are enclosed

Driving Licence OR Passport/Birth Certificate

And additional proof of address e.g. utility bil

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Part 2 (continued)

The Patient Representative Authority Consent Form below, must be completed and signed by the
patient in order that we can release the information requested.

I give permission for the individual named below to submit this request on my behalf and for all
correspondence to be sent to them.

Name in block capitals:…………………………………………………………………………………………

Signed (patient)………………………………………………………………………………………………….

Name of the person acting on behalf of the patient:…………………………………………………………

Address:………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………..

……………………………………………………………….Postcode…………………………………………

Relationship to patient…………………………………………………………………………………………..
(please attach copies of any relevant legal documentation if applicable)

Subject Access Request Department

Manchester Royal Infirmary
Oxford Road
Manchester M13 9WL

When completed, please return this form to the above address.