Section 3. Details of Information Requested In order for us to identify exactly what information to provide from the health records it would be helpful if you could complete the table below in as much detail as possible to identify the period(s)/episode(s) of care that you wish to obtain information about. Patient Hospital Number (If known) ..................................... Period Covered Hospital Ward/Department/ Consultant Diagnosis / (From - To) Attended Specialty (If Reason for visit Section 4 Applicant’s Signature Signed........................................................................ Date............................ Patient Authorisation to Grant access to a Nominated Representative I am the patient whose details appears in Section 1 and give authorisation for the applicant whose details appear in section 2 to be provided with access to my Health Records covering the periods and episodes of care detailed in Section 3. Signed......................................................................... Date................................... Please return the completed form to: Disclosures Team University Hospital Southampton Unity 12 CIC 9-19 Rose Road Southampton SO14 6TE Tel inquiries: 023 8120 4885 e-mail inquiries: hrcinfoteam@uhs.nhs.uk
Section 3. Details of Information Requested In order for us to identify exactly what information to provide from the health records it would be helpful if you could complete the table below in as much detail as possible to identify the period(s)/episode(s) of care that you wish to obtain information about. Patient Hospital Number (If known) ..................................... Period Covered (From - To) Hospital Attended Ward/Department/ Specialty Consultant (If Diagnosis / Reason for visit Section 4 Applicant’s Signature Signed........................................................................ Date............................ Patient Authorisation to Grant access to a Nominated Representative I am the patient whose details appears in Section 1 and give authorisation for the applicant whose details appear in section 2 to be provided with access to my Health Records covering the periods and episodes of care detailed in Section 3. Signed......................................................................... Date................................... Please return the completed form to: Disclosures Team University Hospital Southampton Unity 12 CIC 9-19 Rose Road Southampton SO14 6TE Tel inquiries: 023 8120 4885 e-mail inquiries: hrcinfoteam@uhs.nhs.uk