Health Record Request Form Template for England and Wales

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Key Requirements PROMPT example:

Health Record Request Form

"I need a Health Record Request Form for my elderly mother who lacks mental capacity, where I will be requesting her complete medical history from January 2025 onwards as her legal power of attorney to coordinate her ongoing care needs."

Document background

The Health Record Request Form serves as a standardized mechanism for individuals to exercise their legal right to access their medical records under English and Welsh law. This document is essential for maintaining transparency and compliance with data protection regulations while ensuring secure and appropriate access to sensitive health information. The form is designed to capture all necessary information required by healthcare providers to process such requests, including patient identification, specific records being requested, and any relevant authorizations. It incorporates requirements from key legislation including the UK GDPR and Data Protection Act 2018, making it a crucial tool for both healthcare providers and patients in managing health information access.

Suggested Sections

1. Patient Details: Full name, date of birth, NHS number, contact details including address, phone and email

2. Request Details: Specific records requested, date range of records, preferred format of delivery (electronic/paper)

3. Identity Verification: Section for providing proof of identity details and verification method

4. Data Protection Statement: Information about how the request will be processed under UK GDPR and Data Protection Act 2018

5. Declaration: Patient confirmation and signature section, including date and understanding of process

Optional Sections

1. Third Party Authorization: Section to be completed when someone other than the patient is requesting records, including legal authority verification

2. Urgent Request Details: Additional section for cases requiring expedited processing, such as for ongoing medical treatment

3. Deceased Patient Information: Section for requests regarding deceased patients' records, including proof of authority to access

4. Specific Exclusions: Section where patient can specify any parts of their record they do not wish to access

Suggested Schedules

1. Schedule 1 - Acceptable ID Documents: List of acceptable forms of identification and verification documents

2. Schedule 2 - Fee Schedule: Details of any applicable fees and payment methods (if relevant)

3. Schedule 3 - Privacy Notice: Detailed information about how the request and personal data will be processed

4. Schedule 4 - Patient Rights: Summary of patient rights under UK GDPR and relevant healthcare legislation

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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Authors

Alex Denne

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