Request Access to Patient Records

Form for requesting Access to Patient Records

Please read notes before completing Form
Access request type:*

I am requesting access to a patients records.I am requesting access to a Deceased patients records

Form for requesting Access to Patient Records

Please read notes before completing Form
Request for Access to a Patient’s Healthcare records.

Under the Access to Health Records (NI) Order 1993 (AHR Order)

Please read notes before completing Form
I am requesting access to (please tick as appropriate):-*

My own personal record. Please complete sections A, C, D & ERecords belonging to another living individual. Please complete sections A, B, C, D & E
NOTES:
• You have the right to request a copy of your own personal information held by the Ulster Independent Clinic Ltd, or to authorise someone else to make a request for you. This is known as making a ‘subject access request’ or SAR. Completing this standard form will make it easier to deal with your SAR. Further details can be found on the Information Commissioner’s website:https://ico.org.uk/your-data-matters/your-right-to-get-copies-of-your-data/
• Access to personal information of a living individual is provided free of charge. However, under the terms of the UK GDPR, the Ulster Independent Clinic Ltd reserves the right to charge a fee or to refuse to respond to a request that is made repeatedly, manifestly unfounded or excessive.
• To allow us to validate and process your request, it is important that you complete ALL relevant sections of this Form and provide all necessary documentation, including proof of your identity and address. The timeframe for processing a request will not commence until your request has been validated.
• Acceptable proof of identity includes, for example, a copy of your passport, driving licence, or Translink Senior Citizen Smart Pass. Where your ID documents do not contain your current address we may ask you to verify this.
• Your request will be processed without undue delay and responded to, at the latest, within one month of receipt. This time may be extended by a further two months if your request is complex.

SECTION A – Details of the person the records relate to:
Name:*

Surname:First name(s):
Date of Birth: *

DayMonthYear
Date
Former Name:
Current Address:*
Postcode:*
Tel. Number:*
Email Address

Confirmation Emailexample@example.com
Any Previous Address:
Hospital / Healthcare Number:

SECTION B – Details of the person requesting the records (if different from section A above)
Name:*

Surname:First name(s):
Current Address:*
Postcode:*
Tel. Number:*
Email Address

Confirmation Emailexample@example.com
Relationship to the named Patient / Client:*

SECTION C – Details of the record(s) you wish to access
Type of Service(s) Received: *
Date(s) of treatment or service provided:
(i.e. from / to)
Doctor / Health Professional / staff seen (if known):

SECTION D – Authorisation and Proof of Identity.
In all cases a form of identification is required and must be provided with completed applications.
Please also select 1, 2, 3 or 4 from the following options; (if 4, please also select further criteria)*

1) I am the patient and enclose proof of my identity (copy of ID documents)2) I have parental responsibility however the child is capable of understanding this request and I attach their written consent allowing me to access their personal information on their behalf3) I have parental responsibility and the child named above is NOT capable of understanding this request or consenting to the release of his/her records. I am acting in his/her best interests.4) I am acting as an advocate on the patient’s / client’s behalf and confirm that either:
4) Further criteria:*

The patient / client is an adult and capable of understanding this request and has asked that I act on their behalf. Their written signed consent is enclosed along with a copy of ID for myself and for the patient/clientThe patient/client is an adult and NOT capable of understanding the request. I confirm that I am acting on their behalf and in their best interests. I understand that capacity will be checked with relevant health professional(s) and records will only be disclosed if, in theopinion of the relevant professional, it is in the patient’s / clients best interests. If approved,I understand that any access provided will be limited to information that will meet the needsof the patient/client.
Proof of Identity:*

Accepted File Types: pdf, doc, docx, jpg, jpeg, png
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Proof of Consent: *

Accepted File Types: pdf, doc, docx, jpg, jpeg, png
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SECTION E – 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 records / information referred to.
• I understand that applications received without the necessary ID / consent / documentation will
not be processed and will be returned.
• I understand that the Ulster Independent Clinic Ltd is no longer responsible for the security and
confidentiality of any patient / service user records that have been photocopied and supplied to
me. I confirm I will take all necessary steps to keep secure any information contained in those
records and will dispose of the records by confidential means when they are no longer required.
Applicant’s signature: *

Clear
Date:*

DayMonthYear
Date
Return the completed and signed subject access form along with supporting documents to:
Data Protection Officer; Ulster Independent Clinic Ltd, 245 Stranmillis Road, Belfast, BT9 5JH

Tel: 028 90661212
Email: secretary@uic.org.uk
The Ulster Independent Clinic is a company Limited by guarantee, register in Northern Ireland. Registered number: NI12066, Registered Office: 245 Stranmillis Road, Belfast, BT9 5JH. Registered with The Charities Commission for Northern Ireland NIC103565.

Form for requesting Access to Deceased Patient Records
Request for Access to a Deceased Patient’s Healthcare records.

Under the Access to Health Records (NI) Order 1993 (AHR Order)

Please read notes before completing Form
Whilst the UK General Data Protection Regulation (GDPR) provides a living individual with the right to obtain a copy of their own personal information (this is called a ‘subject access request’), this legislation and right of access does not apply to the records of a deceased person. Due to a duty of confidentiality that remains after a person’s death, a Next of Kin does not have an automatic right to access the health records of a deceased relative or friend. Such access can only be provided in limited circumstances.

The law in relation to access to a deceased person’s medical or health records is the Access to Health Records (Northern Ireland) Order 1993; however Article 5(1)(e) of the Order provides that an application for a deceased person’s health records may only be made by either :

• the legally appointed personal representative of the deceased (i.e. an executor or administrator of a Will to enable them to carry out their duties); or

• any individual who has a claim arising out of the death (for example, a claim against the estate of the deceased).

In all cases, legal proof of entitlement is required before a request for a deceased person’s healthcare records can be processed under the legislation.

The AHR Order does not recognise Next of Kin on its own, as a personal representative with the right to access a late relative’s health records; and, in Northern Ireland, Power of Attorney does not apply to health care decisions and ceases to apply on the death of an individual so cannot be used as proof of entitlement.

It is also important to note that under Article 7(4) of the Order, there is no automatic right of full unrestricted access to a deceased person’s healthcare records and only information relevant to the claim arising out ofthe death will be considered for disclosure

Applications under the AHR Order must therefore be accompanied by the documentation listed at
Section C along with specific details of the records required and how these are relevant to your request.

Access to a deceased person’s confidential healthcare records cannot be provided to anyone without the valid legal authority to do so. Where legal documents are not available as evidence of legal authority but the family of the deceased have a query or concern about their relative’s care or treatment, they should contact the health professionals involved in the first instance. While there is no legal entitlement other than the limited circumstances covered under the Access to Health Records legislation (as specified above), health professionals have always had discretion to disclose relevant information directly to a deceased person’s relatives or others when there is a clear justification.

For valid requests and following receipt of all required documentation, the AHR Order allows up to 40 days to respond to a request. Relevant records will be reviewed by a health professional(s) before their release.

Further information can be found here https://www.health-ni.gov.uk/articles/access-health-records-northern-ireland-order-1993

SECTION A – Details of the deceased person the records relates to:
Name:*

Surname:First name(s):
Former Name:
Date of Birth: *

DayMonthYear
Date
Date of Death:*

DayMonthYear
Date
Hospital / Healthcare Number:
Address:*
Postcode:*
Any Previous Address:

SECTION B – Details of the person requesting the records
Name:*

Surname:First name(s):
Applicant's Address:*
Postcode:*
Tel. Number:*
Email Address

Confirmation Emailexample@example.com
Relationship to the named Patient:*

SECTION C – Evidence of Authority to the requested records
Please indicate by ticking at least one of the following boxes:*

I have been appointed personal representative of the deceased patient and enclose a copy of Grant of Probate documentation issued to me as Executor of the ‘Will’I enclose a copy of the Will which shows my appointment as Executor appointed to manage the personal affairs of the deceasedThe patient died without making a Will and I enclose a copy of Grant of Letters of Administration issued to me as personal representative (Administrator) of the deceased under the rules of intestacyI enclose a formal letter from a Solicitor or Court office confirming my appointment as the personal representative of the deceasedI enclose a formal letter from a Solicitor pursuing a claim arising out of the patient’s death
In addition to the above:*

I also enclose proof of my identity, including my address details
*NB. In cases where there is more than one Executor of the Will, please provide written consent and a copy ID from all Executor’s.
Attached Evidence:*

Accepted File Types: pdf, doc, docx, jpg, jpeg, png
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SECTION D – Details of the record(s) you wish to access
Type of Service Received: *
Date(s) of treatment or service provided relevant to your request
(i.e. from / to)
Doctor / Health Professional / staff seen (if known):
Additional Information on why the above records are relevant to my request:

SECTION F – DECLARATION
I declare that the information and documentation given by me is correct and valid to the best of my knowledge and that I am entitled to apply for access to the records referred to.

I understand that I do not have an automatic right to access the health records of the deceased and that my application will not be processed without valid legal authority and ID (such as a copy of passport, driving licence, Translink Senior Citizen Smart Pass, electoral card, birth certificate or medical card).

I understand that the Ulster Independent Clinic is no longer responsible for the security and confidentiality of any patient records which are photocopied and supplied to me. I confirm I will take all necessary steps to keep secure any information contained in those records and will dispose of the records by confidential means when they are no longer required.
Applicant’s signature: *

Clear
Date:*

DayMonthYear
Date
The Ulster Independent Clinic is a company Limited by guarantee, register in Northern Ireland. Registered number: NI12066, Registered Office: 245 Stranmillis Road, Belfast, BT9 5JH. Registered with The Charities Commission for Northern Ireland NIC103565.

By submitting this form I hereby affirm that all information submitted in this form is accurate, complete, and true to the best of my knowledge. I understand that providing false or misleading information may result in penalties or legal consequences.
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Form for requesting Access to Patient Records

Form for requesting Access to Patient Records

Form for requesting Access to Deceased Patient Records