1 – Guidance Notes
ACCESS TO RECORDS UNDER THE DATA PROTECTION ACT (GENERAL DATA PROTECTION
REGULATIONS) 2018
NOTES FOR APPLICANTS
Please read these guidance notes before completing the Application Form
Note 1 (Part A) – Identity of the person about whom the information is requested
This part must be completed for all applicants.
Complete all details relating to the person whose records you wish to access. This should include former
names (e.g. maiden name) and previous address, if applicable, for the period relating to the record
requested.
If requesting access to health records please provide the Hospital Registration Number and NHS Number
if known.
Note 2 (Part B) – Details of the information required.
This part must be completed for all applicants.
If requesting access to health records you must specify the records you wish to access and provide as
many details as possible. It is not sufficient to state “all records”. There are a number of clinical documents
that are not stored within our main patient records. Please provide details of both the department or data
type (list provided below) and dates relating to each. This will ensure we are able to respond in a timely
manner by helping to identify the documents you require:
- Physiotherapy
- Accident and Emergency (CAS Card only)
- Clinical Measurement Unit (pacing records and ICD only)
- Medical Photography
- Dietetics
- Occupational Therapy
- Critical Care; ITU Charts, CTGs
- Sexual GUM Clinic
- Surgical Appliances
- Maternity Hand Held Pregnancy Records
- Orthoptics Department
- Post-mortem records
- Community Specialist Nurses
- Community Services
- Imaging; CT Scans, MRI Scans, Ultrasounds and X-rays (Please see Note 3)
- Single Assessment Yellow (SAP) Folder
If there is insufficient space, please attach a continuation sheet to your application form.
Note 3 (Part B) – Imaging; CT Scans, MRI Scans, Ultrasounds and X-Rays
Images are provided online via a secure Image Exchange Portal (IEP). This requires two email addresses
or an email address and a mobile phone number. You will be sent an email with a link to set up your IEP
account (Please be advised Emails may get directed to your Junk Mail Folder).
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After setting up your account you will then receive a unique password to access your images. Please be
advised images may take up to 72 hours to be available. Access to images not viewed within 30 days of
account set up will be revoked.
Note 3 Continued –
This IEP service applies to Imaging ONLY. All other health care records and documentation will be
provided separately in hard copies and sent by recorded delivery or can be collected from the Health
Records Library.
Disclaimer: To maintain security of your data please do not access or download images using a
public/shared device or computer. Once you have access the images you are responsible for any
subsequent use and security.
Note 4 (Part C) – Declaration
This part must be completed by the person seeking access.
Sign and date in the space provided.
You will need to supply a form of identification: either a current photo driver’s licence or a current photo
passport.
If applying on behalf of a patient, a copy of the authority confirming you are the personal representative or
executor of the estates for the deceased e.g relevant pages of the will.
For access to Healthcare Records for Children:
Proof of relationship to child, evidence of adoption order, evidence of appointment as guardian, evidence
of residence order, evidence of parental order, evidence of Emergency Protection Order; Interim Care
Order or Full Care Order.
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. Photocopies are acceptable, DO
NOT send original documents.
Once the details in sections A to C have been completed the person should sign and date in the space
provided to officially authorise the applicant’s request for access.
General Notes:
Please note there will no longer be a charge for accessing your medical records, However, we can charge
a ‘reasonable fee’ when a request is deemed repetitive or excessive.
We have 30 days to comply with GDPR, the 30 days start from the date we receive a fully completed
application form which gives us the relevant information to proceed. Please note that under GDPR where
requests are complex or numerous, the period of compliance can be increased by a further two months, If
this is the case for your request, you will be notified by letter within 30 days of receipt of your completed
form
1. WARNING – It is a criminal offence to make false or misleading statements in order to obtain
information.
2. Individuals have a right to confidentiality of their personal health information, even following their death,
and the Trust must be satisfied that an applicant is the person’s authorised representative. This may
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involve checking the identity of any of the named persons on the completed application form and their
validity to request access.
3. 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.
Please retain pages 1 – 3 for your information and return the completed Appendix 2 Form to:
Patient Records Requests Access to Health Records
or Complaint Requests Route 144
or PALs Requests Walsall Healthcare NHS Trust
Manor Hospital
Moat Road
Walsall
WS2 9PS
Email: wht.sars.hrdb@nhs.net
Employee/Ex-employee Requests Human Resource Manager
Route 301
Manor Learning Conference Centre
Walsall Healthcare NHS Trust
Manor Hospital
Moat Road. Walsall. WS2 9PS
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Appendix 2 - Application for information from Manual / Computerised Records
under Article 15 of the General Data Protection Regulations 2018
PLEASE COMPLETE IN BLOCK CAPITALS (with the exception of email addresses)
Part A – Identity of the Person about whom the information is requested (The Data Subject - see note 1)
SURNAME: FORMERLY: Mrs
Ilibagiza
FORENAME(S): Yvonne DATE OF BIRTH:21 march 1975
CURRENT ADDRESS: PREVIOUS ADDRESS:
24 horton street,darlaston
53 aston road, wv13 3dg
MOBILE NUMBER:07707519774 HOME TEL NUMBER:
HOSPITAL NUMBER: 300705375 NHS NUMBER:6492367723
EMAIL ADDRESS:
tutuanike@yahoo.com
Identity of person making the request if on behalf of a patient:
SURNAME Bizimana FORENAME: Bruno
PREVIOUS SURNAME(S): DATE OF BIRTH: 24 july 2002
CURRENT ADDRESS: TEL NO: N/A
53 aston road wv13 3dg
RELATIONSHIP TO PERSON: mom
EMAIL ADDRESS: bizimanabruno387@gmail.com
PART B - Details of the information required (see note 2)
Department Brief details of data required Approximate date(s)
Physiotherapy I need a letter for Medical record for physiotherapy
If requesting Images:
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Image Exchange Portal (IEP)
Two of the following contact details must be provided: (See Note 3)
Email Address tutuanike@yahoo.com
Mobile Phone Number 07707519774
Secondary Email Address saratayo@yahoo.com
(If you do not have a mobile
phone number)
Part C – Declaration (see note 4 )
I declare that the information given is correct to the best of my knowledge and that I am entitled to apply for
access to the information detailed above.
SIGNED:Yvonne Ilibagiza
PRINT NAME: Yvonne ilibagiza
DATE:10 september 022
IF POLICE – PC NUMBER:
Please confirm the details of the identification enclosed with the application (please see Note 4)
x Photocopy of current photo driver’s licence
Photocopy of current passport
Photocopy of birth certificate
Photocopy of proof of address
Photocopy of proof of relationship to child
Confirmation the applicant is the personal representative of the deceased i.e. Power of Attorney, copy of will
WARNING – It is a criminal offence to make false or misleading statements in order to obtain
information
