I have full parental responsibility for the patient and the patient is under the age of 18  and: has consented to my making this request, or is incapable of understanding the request (delete as appropriate) I have been appointed by the court to manage the patient’s affairs and attach a certified  copy of the court order appointing me to do so I am acting in loco parentis and the patient is incapable of understanding the request  I am the deceased person’s Personal Representative and attach confirmation of my  appointment (Grant of Probate/Letters of Administration) I have written, and witnessed, consent from the deceased person’s Personal  Representative and attach Proof of Appointment I have a claim arising from the person’s death (Please state details below)  Signature of applicant: ...................................................... Date: ……………………….. You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution. Section 4: Proof of identity Please indicate how proof of ID has been confirmed. Please select or ‘A’ ‘B’: Method in which identity is Option Documents attached confirmed taken A Attached copies of documents as Yes/No If Yes, please indicate here noted in section 4A below which documents have been attached B Countersignature (section 4B). This should Yes/No Please indicate reason why this only be completed in exceptional section was completed circumstances (e.g. in cases where the above cannot be provided) 4A Evidence – Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are: Type of applicant Type of documentation A An individual applying for his/her One copy of identity required, own records e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. B Someone applying on behalf of an One item showing proof of the individual (Representative) patient’s identity and one item showing proof of the
 I have full parental responsibility for the patient and the patient is under the age of 18 and: has consented to my making this request, or is incapable of understanding the request (delete as appropriate)  I have been appointed by the court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so  I am acting in loco parentis and the patient is incapable of understanding the request  I am the deceased person’s Personal Representative and attach confirmation of my appointment (Grant of Probate/Letters of Administration)  I have written, and witnessed, consent from the deceased person’s Personal Representative and attach Proof of Appointment  I have a claim arising from the person’s death (Please state details below) Signature of applicant: ...................................................... Date: ……………………….. You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution. Section 4: Proof of identity Please indicate how proof of ID has been confirmed. Please select ‘A’ or ‘B’: Method in which identity is confirmed Option taken Documents attached A Attached copies of documents as noted in section 4A below Yes/No If Yes, please indicate here which documents have been attached B Countersignature (section 4B). This should only be completed in exceptional circumstances (e.g. in cases where the above cannot be provided) Yes/No Please indicate reason why this section was completed 4A – Evidence Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are: Type of applicant Type of documentation A An individual applying for his/her own records One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. B Someone applying on behalf of an individual (Representative) One item showing proof of the patient’s identity and one item showing proof of the
Application%20form%20for%20access%20to%20health%20records%20may18%20data%20subject%20access%20request.docx