Request for Records (Subject Access Request) Form

In order to comply with your request, please inform us with precisely what information is required. 

Once this information, alongside a copy of your photo ID is received, we will provide the information within one month. Where we are unable to meet this deadline, we will write to you to explain why.

Generally, there is no charge for the information. However, organisations can charge a “reasonable fee” for the administrative costs of complying with a request when it is manifestly unfounded or excessive, particularly if it is repetitive. If this applies to your request, a member of staff will contact you to explain the fee and the reasons it is being charged.

Please select below to let us know what information you require: **Please note, it may be quicker for us to provide particular parts of a record compared to a whole record

If you selected partial records, please provide a date range:

Partial records from:
Partial records to:
OR pick one or more from the list below:
Letters date range from:
Letters date range to:
Nursing Notes date range from:
Nursing Notes date range to:
Rehabilitation Team Notes date range from:
Rehabilitation Team Notes date range to:
Other information date range from:
Other information date range to:
Who is making the request? If you are an employee, skip to Section D

Section A - 'I am the patient'

Please provide us with the following details:

Date of Birth:
Current address:

We will need you to send a copy of photo ID with your request to prove your identity

Section B - 'I am acting on behalf of the patient'

Is the patient deceased?
Who are you?
Patient Date of Birth:

We will need a copy of photo ID from you, and proof that the patient has 
consented to you receiving their information

Section C - ‘I am acting on behalf of the patient’

You will only need to complete this section if the patient is deceased.

Who are you?

Please provide details of the deceased:

Patient Date of Birth

Section D - I am an employee/ex-employee at the Trust

Date of Birth:

You will need to provide a copy of your photo ID to prove your identity.

Please provide information about any persons who you believe may hold copies of the information requested. This is particularly useful if the data requested includes letters and e- mails as these may be held in local e-mail accounts and not network drives therefore not identified by routine system data searches.

Patient consent

I hereby authorise the Clatterbridge Cancer Centre NHS Foundation Trust to release the information requester to myself, or to the person making the request on my behalf.

Date:
Required