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Wednesday 22 November 2017
Derbyshire Healthcare NHS Foundation Trust
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Application form to request access to a deceased patient’s health record

Strictly confidential once completed

The Trust appreciates this is likely to be a distressing time for you and we wish to make the application process to see the health record as stress free as possible. With this in mind, please complete the relevant sections of this online form to assist us in completing your request as timely as we are able.

Rights of Access

Requests for access to health records of patients who are deceased are dealt with through the Access to Health Records Act 1990 (AHRA).There are certain individuals who have rights of access to the health records of a deceased person.  These are:

The patient’s personal representative

A personal representative is the executor or administrator of the deceased person’s estate.An example of where we are able to confirm that the applicant is a personal representative of the patient is when the applicant is, or has been, the Executor of the Will and they have sent us copies of documents as evidence of this relationship.


Any person who may have a claim arising out of the patient’s death

If the application is in respect of a claim arising from their death, access cannot be given to information which is obviously not relevant to the claim
The law requires us to ask you for information to determine your right to access the health record.If you are applying to see a deceased relative’s record we will need to see one of the following:

  • Grant of Probate
  • Letter of Administration
  • Last Will and Testament.


If you do not have any of these, we need proof of your entitlement to access the record, such as the deceased’s

  • Birth Certificate
  • Marriage Certificate
  • Death Certificate.


Limitations to accessing the record or part of the record

The Trust follows a health records retention schedule whereby records are no longer held for patients who passed away more than eight years ago. We are required to check that any disclosure is subject to the recorded wishes of the deceased person.

We would consult with our health professionals to ensure there is nothing in the record which could harm a third person (such as information about the health of another person) if the record is to be released.  If the health record, or part of the health record is being withheld, we will advise you why, but we would not be able to give you specific details.  If you have any queries, please do not hesitate to contact us – please see details at the end of this form.

» Indicates required fields

Access to a deceased patient’s health record
Documents

Confidentiality
We require you to send us proof of identity by attaching or enclosing a copy of a utility bill showing your current home address and a copy of one of the following photographic IDs: a Medical Card or Drivers Licence or Birth Certificate, or Passport.

Please note that under the Access to Health Records Act 1990, there is no obligation for us to provide records created prior to 1991 unless our relevant Health Professional feels this will help in understanding any records created after this date.

If the records which you are requesting relate to a period prior to 1991, we will have to give consideration to the reasons why you are making this request - please therefore clearly specify why you require these records.

 

Please now enter as much information as you can below. This will help us to deal with your request as quickly as possible. The boxes will expand as you type into them.

Your personal details
Please now enter as much information as you can below. This will help us to deal with your request as quickly as possible. The boxes will expand as you type into them.
If you have an answerphone, are you happy for us to leave messages if necessary?
The patient's details
Gender »
Details of records requested

Please provide as much information as possible, but we realise it may be difficult to do so. It would be helpful if you could tell us the type of record you are wanting to access. Some examples are: Medical/consultant’s file, in-patient nursing, day service, occupational therapy, physiotherapy, community team, child and adolescent, learning disabilities. Please continue on a separate sheet if necessary.

Our fees as set by the Data Protection Act 1998
Copies will be charged at a maximum of £50.  Viewing only will be charged at a maximum of £10.
I would like to be informed of the exact amount of the fee before the information is released to me.  »
There will be no charge if the patient was under our care within the past 12 months.
The patient was under our care in the past 12 months  »
How would you like to receive any information we are able to release to you? »
Paper copies would be posted to you using Royal Mail’s Special Delivery which requires a signature on delivery. Please indicate ‘yes’ if you would like us to contact you to arrange a specific day for delivery when we have completed your request.
Do you wish to view the record with a health professional on Trust premises?
Declaration
Please note that any attempt to mislead Derbyshire Healthcare NHS Foundation Trust in order to obtain patient records may result in prosecution.
I declare that the information I have given on this form is correct to the best of my knowledge and I am entitled to apply for access to the health records referred to above under the terms of the Access to Health Records 1990. »
 

If you have any queries or need help with completing your application please do not hesitate to contact us either by telephone or by email:

Direct dial:01332 623760 Switchboard:01332 623700 ext. 33760

Once completed you can either email your form attaching any relevant documents or post to us.

E-mail: dhcft.accesstoahealthrecord@nhs.net

Postal address:

Access to a Health Record
IM&T and Records
Kingsway House East
Kingsway site
Derby
DE22 3LZ