access form - Rotunda Hospital

ROTUNDA HOSPITAL – Request for Healthcare Records
1. Details of Healthcare records required :(Please use BLOCK LETTERS)
Patient Surname: Patient Maiden Name: Patient First Name(s):
Patient Date of Birth:
Please specify the chart you wish to access:
Maternity [ ] Gynaecology [ ]
Paediatric [ ] Colposcopy [ ]
HARI [ ] Physiotherapy [ ]
Patient Current Address:__________________________________________________
_____________________________________________________________________
Patient Previous Address (if any):___________________________________________
2. Additional Information about the records required:
If you are seeking your records for a specific reason such as you have an appointment
elsewhere or you are attending another service please provide details below:
________________________________________________________________________
________________________________________________________________________
If you need something other than the records above please provide details:
________________________________________________________________________
_______________________________________________________________________
3. Requesters Details:
Requesters Name:
Contact Number:
Requesters Address: ______________________________________________________
Office Use Only
Ref. No: Date received: Signed:
Fee Amount: Date Paid: Signed:
| Routine Access Section, Information Management Department, Rotunda Hospital, Parnell Square,
Dublin 1. Main Office: 8171751 Fax: 01 817 3403

4. Essential Information:
a) This request will be processed in line with Data Protection and therefore only records of a
living individual can be requested with this form and a fee of €6.35 must accompany the
form.
b) Before you are given access to your personal information you will need to provide appropriate
proof of your identity. (i.e. Driver's Licence, Passport etc.) Please note this should match the
name on your records otherwise we may require other supporting documentation.
c) If you are requesting personal information in respect of another person, the original consent
of that person AND a photocopy of their photo ID is required.
d) Your copy records will include written reports, if you require copies of any imaging tests you
may be required to pay for items which need to be copied at cost to the Hospital. You will
need to specify in the additional information section that you require these and you will be
notified of the total fee prior to this copying taking place.
e) There is a postage fee of €10 within Ireland and €30 outside Ireland, this must accompany
your application by way of a cheque or postal order made payable to the Rotunda Hospital.
Patient Accounts will accept cash payments.
f) Please note that for the purposes of processing your request your details will be held on a
database.
5. Requester:
Select an option:
I am requesting my own notes or those of my child who is a minor at the time of request [ ]
I am requesting the notes of another person with their written and signed consent [ ]
(I have attached their written and signed consent and both our ID’s)
I am requesting my own notes or those of my child who is a minor at the time of request, however
I would like these notes to be released to another person/institution as detailed below [ ]
Name :_____________________________________________________________________
Address:____________________________________________________________________
Contact Number:______________________________________________________________
Signed :___________________________
Dated: _________________________
| Routine Access Section, Information Management Department, Rotunda Hospital, Parnell Square,
Dublin 1. Main Office: 8171751 Fax: 01 817 3403