Friends and Family Test

In accordance with the General Data Protection Regulation, patients (data subjects) have the right to access their data and any supplementary information held by Lees Medical Practice. This is commonly known as a data subject access request (DSAR). Data subjects have a right to receive: • Confirmation that their data is being processed • Access to their personal data • Access to any other supplementary information held about them Options for access As of April 2016, organisations have been obliged to allow patients access to their health record online. This service will enable the patient to view coded information held in their health record. Prior to accessing this information, you will have to visit the organisation and undertake an identity check before being granted access to your records. In addition, you can make a request to be provided with copies of your health record. To do so, you must submit a Data Subject Access Request (DSAR) form. This can be submitted electronically and the DSAR form is available on the organisation website. Alternatively, a paper copy of the DSAR is available from reception. You will need to submit the form online or return the completed paper copy of the DSAR to the organisation. Patients do not have to pay a fee for copies of their records. Time frame Once the DSAR form is submitted, Lees Medical Practice will aim to process the request within 21 days; however, this may not always be possible. The maximum time permitted to process DSARs is one calendar month. Exemptions There may be occasions when the data controller will withhold information kept in the health record, particularly if the disclosure of such information is likely to cause undue stress or harm to you or any other person. Data controller At Lees Medical Practice the data controller is Julie Rowe and should you have any questions relating to accessing your medical records, please ask to discuss this with the named data controller.

APPLICATION FORM FOR ACCESS TO HEALTH RECORDS in accordance with the General Data Protection Regulation (GDPR) DATA SUBJECT ACCESS REQUEST

Please enter the details of the applicant if different from Section 1

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the GDPR.

A: An individual applying for his/her own records. One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. B: Someone applying on behalf of an individual (Representative). One item showing proof of the patient’s identity and one item showing proof of the representative’s identity (see examples in ‘A’ above) C: Person with parental responsibility applying on behalf of a child. Copy of birth certificate of child and copy of correspondence addressed to person with parental responsibility relating to the patient D:Power of Attorney/Agent applying on behalf of an individual. Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)

This section is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if 4A cannot be fulfilled.

Before returning this form, please ensure that you have: a) Signed and dated this form b) Enclosed proof of your identity or alternatively confirmed your identity by a countersignature c) Enclosed documentation to support your request (if applying for another person’s records) Incomplete applications will be returned. Please therefore ensure you have the correct documentation before returning the form.