NB: The Data Protection Act states that your CONSENT FORM PATIENT ACCESS TO MEDICAL Stockbridge – RECORDS data cannot be passed to anyone else without SO20 6HG your permission. 01264 810524 I have read and understood this information leaflet about access to my medical record and subject to CONFIDENTIALITY AND PERSONS the information in this leaflet, I consent to No parent/guardian or young person under Stockbridge Practice enabling me access to my electronic health record via the internet. the age of 16yrs will have access to their medical records in accordance with British YOUR CHOICE’ I further agree to use the system in a responsible ‘IT’S Medical Association recommendations. manner with all instructions given to me by Access will be granted to a young person Patient On-Line: Stockbridge Surgery and to immediately report any when they reach 16yrs. The young person errors I encounter whilst using the system. APPOINTMENTS If I see any patient data which does not relate to me I should then complete and sign a consent will immediately log out and report the matter to REPEAT PRESCRIPTIONS form if they wish to have online access. Stockbridge Surgery Parent/Guardian/Young Persons will be MEDICAL RECORDS allowed access to online appointments and Name: repeat prescriptions only. // DOB: If access is required to a Young Persons Telephone No: record by a Parent/Guardian then this Mobile No: would have to be requested/discussed with Email: the GP. Young persons under the age of 16 are sometimes competent to make important Access given to someone other than the patient eg decisions themselves. The Practice will parent/guardian/friend/relative . Please give name of person and their relationship to the patient: take this into account if the young person does not want access to be granted to a parent. Relationship: …………………………………. SIGNED: ……………………………………………. NB. IMPORTANT INFO: Medical Record Access will not be DATED: …………………………………………….. available to Patients they have been YES/NO ID SEEN BY PRACTICE registered for 3 months. Name of Staff Member…………………………. Date: Stockbridge Surgery [Version 4: 31.05.17] New street
NB: The Data Protection Act states that your data cannot be passed to anyone else without your permission. CONFIDENTIALITY AND PERSONS No parent/guardian or young person under the age of 16yrs will have access to their medical records in accordance with British Medical Association recommendations. Access will be granted to a young person when they reach 16yrs. The young person should then complete and sign a consent form if they wish to have online access. Parent/Guardian/Young Persons will be allowed access to online appointments and repeat prescriptions only. If access is required to a Young Persons record by a Parent/Guardian then this would have to be requested/discussed with the GP. Young persons under the age of 16 are sometimes competent to make important decisions themselves. The Practice will take this into account if the young person does not want access to be granted to a parent. NB. IMPORTANT INFO: Medical Record Access will not be available to Patients they have been registered for 3 months. [Version 4: 31.05.17] CONSENT FORM – PATIENT ACCESS TO MEDICAL RECORDS I have read and understood this information leaflet about access to my medical record and subject to the information in this leaflet, I consent to Stockbridge Practice enabling me access to my electronic health record via the internet. I further agree to use the system in a responsible manner with all instructions given to me by Stockbridge Surgery and to immediately report any errors I encounter whilst using the system. If I see any patient data which does not relate to me I will immediately log out and report the matter to Stockbridge Surgery Name: DOB: // Telephone No: Mobile No: Email: Access given to someone other than the patient eg parent/guardian/friend/relative . Please give name of person and their relationship to the patient: Relationship: …………………………………. SIGNED: ……………………………………………. DATED: …………………………………………….. ID SEEN BY PRACTICE YES/NO Name of Staff Member…………………………. Date: Stockbridge Surgery New street Stockbridge SO20 6HG 01264 810524 ‘IT’S YOUR CHOICE’ Patient On-Line: APPOINTMENTS REPEAT PRESCRIPTIONS MEDICAL RECORDS
PATIENT%20ONLINE%20ACCESS%20FORM%20V4.docx