Notes to assist in the completion of Forms DPA1 and AHR1

Request for Access to Personal Information

(Request for Subject Access under the Data Protection Act 1998 or Access to Health Records Act, 1990 [Deceased Patients only]).

Please read all these notes carefully before completing either form DPA1 or AHR1.

Note 1 (Part A)
This section must be completed for all applicants. Please complete all details relating to the person about whom the information is requested. This should include former names (e.g. maiden name) and, if relevant, a previous address. The Name of the General Practitioner (GP) should be given together with the Hospital Registration Number (if applicable).

Note 2 (Part B)
This section must be completed for all applicants. Please specify the records/information you wish to access providing as many details as possible  It is not sufficient merely to state "all records". For health records, please state clearly if you require copy records, copy x-rays or both. If you have insufficient space, please attach a continuation sheet containing full details. Examples are given below:

Hospital	Consultant/Department	Condition or Illness	Approximate Dates	Medical Records	X-rays
Birmingham Women's Hospital	Mr Smith Obstetrician	Pregnancy	December 1997 - January 1999	Yes	Yes

Note 3 (Part C)
Tick appropriate box as to method of access.

Note 4 (Part D)
This section must be completed for all applicants. Part D tells us who you are and must be completed in the presence of an independent (unrelated) witness, who must also complete Part E. Tick one box only which best describes you. Please sign and date the form in the space provided and, if you are not the patient/data subject , provide your address, telephone number and state your relationship to the patient/access subject.

Note 5 (Part E)
This section must be completed for all applicants. The person who witnessed the completion of Part D must complete this section. They should insert their full name, the applicant’s name and the number of years they have known the applicant, in the spaces provided. They should then sign and date, as indicated, and provide their own address and daytime telephone number.

Note 6 (Part F)
For information on charges for applications made under the Access to Health Records Act 1990 (Deceased Patients) see here. You will be contacted in due course and advised of the total amount payable. Payment must be made in full before the copy records can be released. Please do not send any money with this application.

For information on charges for applications made by patient for their own records under the Data Protection Act 1998 see this.here. You will be contacted in due course and advised of the total amount payable. Payment must be made in full before the copy records can be released. Please do not send any money with this application.

Note 7 (Part G) - DPA1 Forms only
This part should only be completed when the applicant is not the patient/access subject but has been authorised by the patient to make the application. The patient should sign and date in the space provided, to officially authorise the applicant's request for access.

General Notes

1. Please complete Form DPA1/AHR1 in block capitals (other than signatures) and in black ink.
2. You are advised that making a false or misleading statement in order to obtain access to personal information to which you are not entitled is a criminal offence.
3. Individuals have a right to confidentiality regarding any information held about them and the Trust must be satisfied that an applicant is the patient/access subject or their authorised representative. This may involve checking the identity of any of the (named) persons on Form DPA1/AHR1, and we may also have to make further enquiries. Where possible, telephone confirmation will be sought. However, it may be necessary to request further proof of identity, e.g. driving licence.
4. Receipt of your completed application form will be acknowledged. Under normal circumstances, all applications will be dealt with within the specified time limits, i.e. within 40 days of receipt. You will be advised of any undue delays.
5. Information may be withheld where it is considered that access might cause serious harm to the physical or mental health of the patient or any other individual, or where a third party might be identified without their consent. There is no requirement to disclose the fact that information has been withheld.
   

This page was last modified on Fri May 07 2010