Subject Access Request Form

Submitting a Subject Access Request (SAR)

Under the Data Protection Act 2018, patients have the right to access the personal data we hold about them. This is called a Subject Access Request (SAR). We will respond within one calendar month of receiving your request. If you are acting on behalf of a patient, please provide their written consent. Complete the form below to submit your request.

Your details
Title
First name * REQUIRED
Last name * REQUIRED
Your email address * REQUIRED
Telephone number * REQUIRED
Your relationship to the patient (if applicable):
Please make available to me the records you hold in relation to:
Date(s) of incident: * REQUIRED
Address/location of incident: * REQUIRED
Patient’s name: * REQUIRED
Requesting records for a deceased patient
Requests for deceased patients’ records are managed under the Access to Health Records Act, 1990. Please also answer the following questions to help us process your request:
Are you the patient’s personal representative? (e.g. executor of the will)
- Yes
- No
Do you have a claim arising from the patient’s death?
- Yes
- No
If you do not meet either of the criteria above, please provide further information to support your request:
Please upload any further documents to support your application.
Max. file size: 150 MB.
Your signature and proof of identity
I declare that the information given by me is correct to the best of my knowledge and that I am entitled to access to the information referred to as above, because:
- I am the patient
- I am acting on the patient’s behalf
Signature of patient
Signature of applicant
Upload ID to verify your identity
Max. file size: 150 MB.

Please upload a form of ID (driving licence or passport, a utility or council tax bill that confirms your name and address) so that we can verify your identity. If you are acting on the patient’s behalf, you will need to provide the individual’s ID. Please also upload any further documents to support your application e.g. Lasting Power of Attorney for Health and Welfare, signed form of authority. If the patient is deceased, you will need to provide proof that you are the patient’s personal represesentative e.g. executor of the will or have a claim arising.
Any other information that supports your application (use box below)
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Subject Access Request Form

Submitting a Subject Access Request (SAR)

Your details

Please make available to me the records you hold in relation to:

Requesting records for a deceased patient

Your signature and proof of identity