Subject Access Request Form – Westbury Avenue Requesting copies of medical records or extract from medical records. This form is for use by Westbury Avenue registered patients only.JS Medical Practice will normally respond to a Subject Access Request within one month of receipt. We may extend the time limit by a further two months if the request is complex or if we receive a number of requests from the individual. This period will not commence until JS Medical Practice is satisfied as to the identity and authority of the applicant. JS Medical Practice may seek further information from the applicant as to the specific information requested. Any request for clarification will suspend the one month period until the required information is received. There is no fee charged for this request. However, we may charge a ’reasonable fee’ for the administrative costs of complying with a request if it is manifestly unfounded or excessive, or if an individual requests further copies of their data. 1. Details of person requesting information (the Applicant):Full Name Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Optional Confirm Email Optional 2. Are you the Data Subject (for example the named individual who the requested medical records refer)? Yes Optional No – I am acting on behalf of the Data Subject with their written authority? If so, the written authority must be included. Optional Details of person acting on behalf of the data subject (applicant).Full Name Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact NumberPlease describe your relationship with the Data Subject that leads you to make this request for information on their behalf: 4. Please give details as to the information you would like to review.What exact part of the medical records do you wish to obtain copies of? Part of the medical records, specifically relating to: Medical records from a specific date range: Copies of the entire medical records including Lloyd George (paper records) Alternatively, if you wish to access your electronic medical records only – this is available via our online access to the EMIS medical records for the Data Subject or carer/parent which is quicker and easier to access and is updated ‘live’ via the EMIS medical records. If you prefer to access your records this way, please ask reception to register you for this service. Please specify Date from: Day Month Year Date to: Day Month Year What is the reason for your request for these records?What is the latest date you need this information by? Day Month Year (N.B. – the practice has 1 month to prepare these records as per the subject access policy, if you need this any sooner, for justifiable urgent reasons, please give your reasons and the latest possible date that this information is needed by and the practice will endeavour to meet the requested date however we cannot guarantee this. Thank you for your understanding). The Practice uses ‘emr by medi2data’ and ‘iGPR’ (IT data processing services) to help us process subject access requests for patient records, ensuring GDPR is followed. The advantage for the practice using these services are that medical records can be presented in a format that can be easily read and understood, sensitive data can be redacted (edited, removed) if needed (please inform us of any information you wish to redact), whilst following strict information governance and data protection procedures. Emr by medi2data and iGPR are bound by strict data protection policies and your medical record will not be viewed or shared by emr and iGPR. *Please note emr by medi2data uses a two-step authentication process for added security. You will be sent a verification code via your mobile phone in order to access and download your medical record securely online via emr. If you do not have access to email, please inform us. Please also ensure your email server allows the email address, [email protected] as you will receive the medical records through here.Third party software consent: Yes No Signed by applicant /data subject/ authorised person Please insert your FULL NAMEDate Day Month Year Please provide the following proof of Identity and authorisation from the Data Subject: Driving licence or, Passport or birth certificate of the data subject. Proof of address, e.g. a utility bill (no longer than 3 months old) of the data subject. And if relevant: A signed letter of authorisation from the data subject consenting that the solicitor can act on their behalf or Lasting Power Attorney. Uploads Drop files here or Select files Max. file size: 50 MB, Max. files: 20. Name OptionalThis field is for validation purposes and should be left unchanged.