Access to Health Records: A Guide for Applicants

Who can apply to access medical records?

• The patient
• Another person (with the patient’s written permission)
• A parent or guardian of a person under 13 (where a child is considered capable of making decisions about his/her medical treatment, the consent of the child must be sought before a person with parental responsibility can be given access)
• A court-appointed representative of someone who is unable to manage their own affairs
• Where the patient has died, the executor as named on the will or anyone having a claim resulting from the death, may apply to see the records or part of them
• The patient’s appointed representative (whilst they were alive) has a legitimate and unfettered right of access to the patient’s records after death.

What are the fees for access?

There is no charge for copies of records supplied under current data protection legislation or the Access to Health Records Act (AHRA) 1990. However, fees can be charged where the request is deemed to be ‘manifestly unfounded or excessive’, or where the request is for a copy of records previously provided on or after 25 May 2018. This will be identified when the application is received by the Trust.

How do I pay if applicable?

If there is a charge applicable for an ‘excessive request’, the Case Note Release team will raise an invoice through NHS Shared Business Services (SBS) online. SBS then sends out the invoice to the requestor’s home address with details of how to pay. Once the invoice has been paid, that is when the work is commenced. The Case Note Release team checks the electronic SBS system regularly to avoid unnecessary delays.

What proof of identity do I need to provide?

For security purposes, the Trust requests identification to formally confirm the individual’s identity. When submitting a request, you must include:

• A form of identification as proof of your name. It doesn’t need to be a photo ID. See examples below.
• AND Proof of your name linked to your address.

You cannot use one form of identification for both your name and address. For example, if you provide your driving licence as proof of your name, you must provide another form of identification for your address, such as a utility bill.

Please note:

• The Trust will accept the overseas equivalent of the listed documents for claimants who live abroad.
• The Trust will not accept the following as ID documents:
  • Provisional driving licence
  • Mobile phone bills
  • Credit or store card statements.

Permitted forms of Name Identification (Choose one of the following):

• Current signed passport
• EEA member state identity card
• Current UK or EEA photo-card driving licence
• Full old-style driving licence
• Original birth certificate (issued within 12 months of the date of birth) in full or short form, including those issued by UK authorities overseas such as Embassies or High Commissions
• Confirmation from DWP of state benefits issued within the current year.
• Residence permit issued by the Home Office to EEA nationals on sight of their own country’s passport.
• Medical card or letter of confirmation from GP’s practice of registration with the surgery.

Permitted forms of Address Validation (Choose one of the following):

• Utility bill (gas, electric, satellite television, landline phone bill) issued within the last three months.
• Water bill issued for the current financial year.
• Local authority council tax bill for the current council tax year.
• EEA member state identity card.
• Current UK or EEA photo-card driving licence.
• Original mortgage statement from a recognised lender issued for the last full year.
• Solicitor’s letter confirming recent (within previous three months) house purchase or current Land Registry title view.
• Council or housing association rent card/statement or tenancy agreement for the current financial year.
• Confirmation from DWP of state benefits issued within the current year.
• Bank, Building Society or Credit Union statement (dated within the last three months) or passbook.
• HMRC self-assessment letters or tax demands dated within the current financial year.
• Medical card or letter of confirmation from GP’s practice of registration with the surgery.

Guidance notes for completion of the application form:

Part A:

Complete all details relating to the person whose records you wish to access. This should include former names and addresses, if applicable, for the period relating to the records requested.

Part B:

You must specify the records you wish to access and provide as many details as possible. It is not sufficient to state ‘All Records’ (GDPR Recital 63), as we may charge a ‘reasonable fee’ if the task is manifestly unreasonable or excessive. If the request is deemed to be ‘manifestly unreasonable or excessive’, we may then take a further month or two – as permitted by law – to satisfy your request. If there is insufficient space, please attach a continuation sheet. If you are making a request through a third party such as a solicitor, then if we think that you may not understand what information would be disclosed to that third party, who has made a subject access request on your behalf, then we may then contact you or send the response directly to you rather than to the third party. You may then choose to share the information with the third party after having the opportunity to review it. Please visit the Information Commissioner’s Office website for further information: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/right-of-access/

Part C:

We require proof of identity before we can process your request. This is to protect the identity of the data subject and ensure that the data protection principles are not breached.

Part D:

This part should only be completed where the applicant is not the patient to whom the records relate, but who has been authorised by that patient to make the application on their behalf.

What will happen after I apply?

• When the department has received the completed application form, the validity of the request is checked to ensure that the person applying has the right to apply, particularly if applying for another person’s records.
• If a fee has been identified (from a manifestly unreasonable request, excessive request or repeat request) and/or postage is the option chosen, the application will not be dealt with until payment is received.
• The relevant medical records are then obtained and scanned.
• If access is granted, the records will be posted out via special delivery (to the address stated on the application form) or available for collection, depending on the option chosen on the application form.

How long will it take?

We aim to make your records available to you within one month of receiving your fully completed request, proof of your identity, and the fee (if applicable). If records are deemed complex or excessively large, then it may be necessary to extend this time period for up to a further two months, and this may also result in an extra fee for excessive data (see Part B guidance). However, if you are specific with your request, there is likely to be no fee as the request would not be classed as excessive.

General Notes:

• Warning – it is a criminal offence to make false or misleading statements in order to obtain information.
• Individuals have a right to confidentiality of their personal health information, and the Trust must be satisfied that an applicant is the person(s) authorised representative. This may involve checking the identity of any of the named persons on the complete application form and their validity to request access.
• Information may be withheld where it is considered that access might cause harm to the physical or mental health of the patient or any other individual, or where a third party might be identified.

Who do I contact if I have any questions?

You can contact the Case Note Release Team at the address below: Case Note Release Team Doncaster Royal Infirmary Armthorpe Road Doncaster DN2 5LT Tel: 01302 642234 or 01302 642235 Email: dbth.casenoterelease@nhs.net

If for any reason you are dissatisfied with our service and wish to make a formal complaint, then please contact:

Patient Advice and Liaison Service (PALS)

The team is available to help with any concerns/complaints you may have about your experience at the Trust. Their office is in the Main Foyer (Gate 4) of Doncaster Royal Infirmary. Contact can be made either in person, by telephone or email. The contact details are: Telephone: 01302 642764 or 0800 028 8059 Email: dbth.pals.dbh@nhs.net