The WWL Way
Telephone: 01942 244 000

Access to Health Records Request Form

Please complete the form below with details of your access to health records request

For your peace of mind, your details are encrypted and sent securely to us. It is important to complete all mandatory fields and as many of the other fields as possible to allow us to identify you.

For your information, the successful submission of your request will be confirmed with the appearance of a thank you message.

* means mandatory field

Please read the accompanying guidance: “Access to Health Records Information Leaflet” regarding the rights of access together with charges that may be associated with your application, to assist you in completing this application form.

Details of applicant

* Your Full Name:

 

* Address:


 

* Postcode:

 

* Telephone Number:

 

* Email Address:

* May we leave an answer phone message:  Yes
 No
* Please tick the appropriate boxes:  I am the patient and over the age of 16 years
 I am the person who has legal responsibility for the patient, 
      who is under the age of 14
 The patient is over 14 years of age and under 16 years of age, 
      has consented to my making this request and has authorised 
      my application
 I am acting on behalf of the patient (aged over 16). Please be
      advised that you will need to provide proof that you have power
      of attorney or that you are the legal representative
 I am the deceased patient’s personal representative and attach
      either letters of administration or a grant of probate
 I have a claim arising from the patient’s death and wish to access 
      information relevant to my claim on the grounds that:
      


Unless you have requested paper copies records will be sent out to you in a password encrypted document on a CD. The password to open this document will be emailed to you.

Details of patient

* Full Name:
* Address:
* Postcode:
* Date of birth:  (e.g. 10/06/1964)
* Title:
* Gender:  Male        Female
* NHS number:
* Hospital number:


If the name and / or address were different from above during the time period(s) to which the application relates - please give details below:

Previous surname: 1)    Applicable dates:
2)    Applicable dates:
Previous address: 1)    Applicable dates:
2)    Applicable dates:


To help the NHS save time and resources it would be helpful if you could provide details, informing us of the parts of the health records you require, along with details which you may feel have relevance i.e. dates, consultant name, location, written diagnosis and reports etc.

* Which records are you requesting? (Please tick the applicable boxes)  WWL Hospital Services (Royal Albert Edward Infirmary, Leigh, 
      Wrightington, Thomas Linacre, Boston House)
 WWL Community Services (Walk In Centre, District Nurse, 
      Mental Health etc.)
 Both

WWL Services:

WWL Hospital / Clinic Contacts (Please provide as much information as possible)

* Please provide date attended, hospital, ward/clinic, consultant name and hospital number: 

   

Type of record (please indicate):
 Case Notes
 X-Rays
 A&E Records
 Photographs

   

Type of record (please indicate):
 Case Notes
 X-Rays
 A&E Records
 Photographs

WWL Community:

WWL COMMUNITY CONTACTS (please provide as much information as possible)

* Name of Service:
(Podiatry, Dietetics etc.)
(if you are unsure of the service
can you provide detail of the treatment received: mental
health, diabetic care etc.)
* Where were you treated?
(Clinic, walk in, home etc.)
Health Professionals Name:
(if known)
Month and year of care
or treatment (if known)
Month and year care
or treatment ended (if known)


Do you wish to arrange an appointment to view the original records in the presence of a member of staff? Please note this will be a member of the Information Governance Team who is not medically trained     Yes     No

I would prefer to receive the records as paper copies      Yes     No

In order that we can process your application request efficiently would you please advise us if this application is in connection with an on-going complaint against the Trust?      Yes      No

If yes, please enter your complaint reference number:



Please enter the characters you see above.



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