Private Services Request Form

 
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All questions marked with a * are mandatory

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Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Private Request Details
Please state the nature of the request i.e. copy of medical record, letter, form to be completed etc.
Please state the purpose of the request i.e. for personal use, school, claim etc.
Please state who will use the information provided if not yourself i.e. insurance co., solicitor, school etc.
i.e. regarding a recent injury / medical problem
FAQ

Do I need to provide consent?

Yes, please ensure written consent is provided at the time of request, otherwise there will be a delay in processing your request.

 

What happens after I complete the request form?

You will be contacted after your request has been received by us and informed of the exact fee that is applicable. This should be paid in advance in full. Your request will then be processed and you will be contact when it is ready to collect / view. If you are paying for the request please note; we only accept cash payment at reception. You will be provided with a receipt of payment for your reference.

 

Can I view my request once it is complete?

Yes, as long as you have requested to view your medical records prior to them being sent off to your insurance company / solicitor. Please let them know in advance. This will delay us sending your records off by an additional 21 days.

 

What happens after my request is ready?

Completed requests can be collected from Monday to Friday between 9-4pm. If someone is collecting on your behalf, please ensure they bring written consent from you that you give permission for them to do so. All requests should be collected within 3 months. They will be discarded after this date and you will have to re-request if you require this information again. The same fees will apply.

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Your Data

Subject Access Requests (SAR)

Summary Care Record

Your Summary Care Record contains important information from the record held by your GP practice and includes details of any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced. Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly. As part of a mandatory national programme each GP Practice had to make a summary care record for each patient by March 2015 (unless the patient has already opted out). You can choose to opt out of this scheme at any time.

If you wish to opt out of the Summary Care Record scheme please complete the opt out form below and return it to us.

To make changes please complete the form below and return it to us.

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Privacy Consent

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