SUBJECT ACCESS REQUEST - Hampshire Hospitals NHS ...

SUBJECT ACCESS REQUEST – APPLICATION FORM
Full Name:
Date of Birth:
Address:
(for access to patient records under Data Protection Act 1998)
Post Code:
Contact Telephone
Number:
Previous Address:
(If relevant to the
request?)
Post Code:
What period does your request cover, or
which year(s) is/are relevant?
A - Identification
Please include (and indicate) a photocopy of one of the following identification documents
and an additional proof of address. Please do not send originals.
Driving Licence:
or
Passport / Birth Certificate:
and additional proof of address:
Please read notes below and supply any additional information overleaf that will enable us
to provide the information you require.
Please supply copies of information that you may hold about me.
I understand that a fee may be required prior to the release of any information.
Signature …………………………………………. Date ………/………/………
Any information you have supplied in making this request will be treated in confidence. It will only be used for
the purpose of carrying out the search for your data,in accordance with Section 7 – Data Protection Act 1998.

Hampshire Hospitals NHS Foundation Trust is only responsible for providing information
which is held by us or by departments within our control.
If you feel you would like to discuss your information request further please telephone or
write to the Access for Health Officer.
B - Third Party Disclosure:
If your request indicates the release of information to a Third Party (e.g. a solicitor,
insurance company or relative), please complete this section.
I hereby give Hampshire Hospitals NHS Foundation Trust permission to send my personal
information collated during the Subject Access Request to the following address:
Full Name:
Address:
Post Code:
Signature …………………………………………. Date ………/………/………
C - Additional Information:
Please provide any additional information that will enable us to find your information?
Please return this form to:
Access to Health Records Officer
Royal Hampshire County Hospital
Romsey Road
Winchester
SO22 5DG
Contact Access to Health: 01962 824407
Please continue on separate sheet if necessary.