Subject Access Request Form – Testing

Submitting a Subject Access Request (SAR)

Patients have the right to request access to the data that we hold about them by submitting a Subject Access Request (SAR) under the Data Protection Act, 2018. We are required by law to respond to a SAR within 1 month. If you are acting on a patient’s behalf, we require their written consent. Complete the form below to complete your request.

Your details
Title
First name * REQUIRED
Last name * REQUIRED
Your email address * 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
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)
CAPTCHA

Subject Access Request Form – Testing

Submitting a Subject Access Request (SAR)

Your details

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

Your signature and proof of identity