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Subject Access Request

Cotswold Medical Practice

 

Subject Access Request Form

 

Subject Access Request (SAR)

 

In order to protect the privacy of the Data Subject (individual) who this request is about and in line with the requirements of data protection &confidentiality legislation, Cotswold Medical Practice needs to ensure we locate the records and information only relating to the Data Subject.

 

Who is completing the form?

 

Please select whether you are filling this form in for yourself as the data subject or for somebody else as their authorised representative.(delete as appropriate)

 

  • I am the data subject.
  • I am completing this form to request information about myself.
  • I am an authorised person.
  • I am completing this form to request information about somebody else with their authorisation.

 

Details of the Data Subject

 

Please fill in your details (the data subject). If you are not the data subject and you are applying on behalf of someone else, please fill in the details of the data subject below and not your own.

 

 

Title:

 

First Name:

 

 

Last Name:

 

 

Previous Name: (If applicable)

 

 

Date of Birth:

 

 

NHS Number: (If known)

 

 

Telephone Number:

 

 

Email Address:

 

 

Address (Including postcode)

 

 

 

 

 

 

Previous address including postcode: (if you are no longer a patient at Cotswold Medical Practice and have moved from your last registered address)

 

 

 

Please state the information you require from Cotswold Medical Practice:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proof of identity

 

We require proof of identity before we can disclose personal data. Proof of identity should include a confirmation of name, e.g., full driving licence, passport, birth certificate, marriage certificate, HSCIC identity card and confirmation of address, e.g., utility bill, bank statement, credit card statement (dated within the last three months).

 

If you are as ex-patient and have changed your name since you were registered at Cotswold Medical Practice, please supply relevant documents evidencing the change.

 

If you are sending this electronically (by email), please ensure all document file names contain the Data Subject's name and date of birth, for example, Mary Delore 22.05.2000 Birth Certificate.doc

 

If you are acting on behalf of the data subject

 

Please complete this section of the form with your details if you are an authorised person acting on behalf of someone else i.e., the data subject.

 

If you are NOT the data subject, but an agent/authorised person appointed on their behalf, you will need to provide evidence of your name e.g.full driving licence, passport, birth certificate, marriage certificate, HSCIC identity card and confirmation of address e.g.utility bill, bank statement, credit card statement (dated within the last three months) as well proof of your right to act on their behalf e.g.,Health and Welfare Lasting Power of Attorney, letter of authority, evidence of parental

responsibility.

 

 

Please ensure all document file names contain your name and the Data Subject's name and date of birth, for example, JosephYildez, Mary Delore 22.05.2000 Birth Certificate.doc.

 

What is your relationship to the data subject?

 

 

e.g., parent, carer, legal representative

Your first name:

 

 

 

Your last name:

 

 

 

Your address including postcode:

 

 

 

Your contact telephone number:

 

 

 

Your email address:

 

 

 

 

 

Dispatch

 

Under the GDPR, we must respond to a subject access request without undue delay and in any event within one month of receipt of the request. We aim to fulfil the majority of SAR requests electronically. You may therefore be given access to download the requested information.

 

If it is impossible for you to access electronic records, you will collect the printed records from the practice and we will let you know when they are ready for collection. You will be required to sign for the records and may again be asked to prove your identity.

 

Please select: (delete as appropriate)

  • I am the data subject and would like my requested data to be provided electronically.
  • I am the data subject and would like to collect a printed copy of my requested data.
  • I am acting on behalf of the data subject and would like the requested data provided electronically.
  • I am acting on behalf of the data subject and would like to collect a printed copy of the requested data.

 

 

Checklist

 

Before you complete the declaration section overleaf, please check:

 

  • Is your contact information correct?
  • Have you completed all the relevant sections?

 

 

Declaration

 

Warning: a person who unlawfully obtains or attempts to obtain data is guilty of a criminal offence and is liable to prosecution.

 

Unless there is Health and Welfare Lasting Power of Attorney or the application is being made on behalf of a child under the age of 13, all persons named on this form should confirm that the information that has been supplied in this application is correct and you are the person to whom it relates or acting on behalf of.

 

Data Subject Declaration

 

 

I certify that the information provided on this form is correct to the best of my knowledge and that I am the person to whom it relates. I understand that Cotswold Medical Practice is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.

 

Sign

 

 

Print Name

 

 

Date

 

 

 

 

 

Authorised Person Declaration

 

I confirm that I am legally authorised to act on behalf of the data subject. I understand that Cotswold Medical Practice is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.

 

Sign

 

 

Print Name

 

 

Date

 

 

 

Please return this form along with your supporting documentation (proof of identity and, if applicable, proof of your right to act) to:

 

Julia Tambini(Data Protection Officer)

Moore Health Centre

Moore Road

Bourton on the Water

GL54 2AZ

 

Please mark your envelope on the outside: SAR REQUEST

If sending the request electronically, please email to: juliatambini@nhs.net



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