Case Details
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Request for Access to Records.

Records to be accessed (Patient / individual's details)

Data Subjects Name:*
DS Previous/Other Names:
DS Date of Birth:*
DS Address Line 1:*
DS Address Line 2:
DS Town:*
DS County:*
DS Postcode:*
DS Previous Address:
Hospital number:
NHS Number:

Details of your Request.

Please provide as much information as possible to enable us to locate the relevant records required. For example, the type of records required including any Radiology Images e.g x-rays, CT scans etc.
Request:*
From Date:*
To Date:*

Information about you. Applicants Details.

Contact/Requestor:*
ContactAddress1:*
ContactAddress2:*
ContactTownCity:*
ContactCountyState:*
ContactZipPostcode:*
Phone No:*
E-Mail:*
Organisation Reference:

Authorisation and Identification

Please answer ALL the appropriate statements below and use the ATTACH A FILE to upload documents.

If applying for access to your own records you will need to send proof of identity. Please send a copy of your passport, photo driving licence or sufficient equivalent identification.

If you do not hold photographic identification, please provide two forms of identification that confirm your current address and date of birth. Examples of suitable identification include a full birth certificate and a current utility bill/bank statement etc.

If you are applying for records on behalf of a patient, you will need to send proof of your identity AND proof of identity for the patient together with the relevant authorisation from the patient.

Proof of Identification

I am requesting access to my own records and have attached proof of identification.

Proof of ID:*

Acting on behalf.

I am acting on behalf of the patient / individual to whom the information relates. I have attached consent that I can act on their behalf, together with proof of identify for the patient / individual and myself.

Acting on behalf:*

Parental responsibility for a patient UNDER 13.

I am the person who has parent responsibility for a patient under the age of 13. I have attached proof of Parental Responsibility, and proof of identify for the patient and myself.

Parental under 13:*

Parental responsibility for a patient OVER 13.

I am the person who has parental responsibility for a patient over the age of 13. I have attached proof of Parental Responsibility and consent from the patient that they are happy for me to make this request on their behalf, and proof of identify for the patient and myself.

Parental over 13:*

Appointed by the Court

I have been appointed by the Court to manage the patient’s affairs. I have attached a certified copy of the Court Order appointing me to do so and proof of my identity.

Appointed by the court:*
Attach a file

Declaration

By submitting this request I certify the information provided on this form is true. I understand Wirral University Teaching Hospital is not obliged to comply with my request unless they are supplied with such information as they may reasonably require in order to satisfy themselves as to my identity and to locate the information which I seek.

Warning – a person who unlawfully obtains, or attempts to obtain, personal information is guilty of a criminal offence and is liable to prosecution.