Make a Subject Access Request | North Bristol NHS Trust

In order to protect the privacy of the Data Subject (individual) who this request is about and in line with the requirements of data protection & confidentiality legislation, North Bristol NHS Trust needs to ensure we locate the records and information only relating to the Data Subject.

A Subject Access Request can be made by completing and submitting the online form below.

Who is completing the form?

Please select whether you are filling this form in for yourself as the data subject or for somebody else as their authorised person.

I am the data subject. I am completing this form to request information about myself.

I am an authorised person. I am completing this form to request information about somebody else with their authorisation.

Details of the Data Subject

Please fill in your details (the data subject). If you are not the data subject and you are applying on behalf of someone else, please fill in the details of the data subject below and not your own.

Title:

Please enter title

First name:

Last name:

Previous name (if applicable):

Date of birth:

Gender:

NHS number (if known):

Mobile number:

Email address:

Confirm your mobile number

Confirm email address:

Address:

Postcode:

Previous addresses including postcode (if applicable):

Please state the information you require from North Bristol NHS Trust:

If you only want to know what information is held in specific records please indicate. Please tell us if you know in which capacity the information is being held, together with any names or dates you may have. If you do not know exact dates, please give the year(s) that you think may be relevant.

Do you require?

Radiology only

Medical notes only

Radiology and Medical notes

Proof of identity

We require proof of identity before we can disclose personal data. Proof of identity should include a confirmation of name e.g. full driving licence, passport, birth certificate, marriage certificate HSCIC identity card and confirmation of address e.g. utility bill, bank statement, credit card statement (dated within the last three months).

If you have changed your name, please supply relevant documents evidencing the change.

Please ensure all document file names contain the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc

Proof of name

Please ensure all document file names contain the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc
Upload requirements

Proof of address

Please ensure all document file names contain the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc
Upload requirements

Evidence of name change (if applicable)

Please ensure all document file names contain the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc
Upload requirements

If you are acting on behalf of the data subject

Please complete this section of the form with your details if you are an authorised person acting on behalf of someone else i.e. the data subject.

If you are NOT the data subject, but an agent/authorised person appointed on their behalf, you will need to provide evidence of your name e.g. full driving licence, passport, birth certificate, marriage certificate HSCIC identity card and confirmation of address e.g. utility bill, bank statement, credit card statement (dated within the last three months) as well proof of your right to act on their behalf e.g. Health and Welfare Lasting Power of Attorney, letter of authority, evidence of parental responsibility.

Please ensure all document file names contain your name and the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc.

What is your relationship to the data subject?

Your first name:

Your last name:

Your address including postcode:

Your contact telephone number:

Your email address:

Confirm your email:

Evidence of your name

Please ensure all document file names contain the your name and the Data Subject's name and date of birth, for example, Dave Smith 22.05.2000 Birth Certificate.doc.
Upload requirements

Evidence of your address

Upload requirements

Proof of authorisation to act on behalf of the data subject

Upload requirements

Dispatch

Please indicate where you would like your records dispatched:

I am the data subject and would like my records to be dispatched to my email address as detailed above

I am acting on behalf of the data subject and would like the records dispatched to the email address as detailed above

I would like my records to be dispatched to my GP or Healthcare Professional or Solicitor (or other 3rd Party)

North Bristol NHS Trust will provide any requested information electronically if an email address is supplied. Any documents will be either encrypted or password protected. Please note that if information needs to be posted by Royal Mail special delivery, a signature upon receipt will be required. If Royal Mail are unable to deliver to the address given and need to return the documentation to North Bristol NHS Trust this will be returned by normal post (i.e. not under confidential cover).

Please provide 3rd party details for dispatch.

3rd party name:

3rd party address:

3rd party email address:

Checklist

Before you complete the declaration section please check:

Is your contact information correct?

Have you completed all the relevant sections?

Declaration

Warning: a person who unlawfully obtains or attempts to obtain data is guilty of a criminal offence and is liable to prosecution.

Unless there is Health and Welfare Lasting Power of Attorney or the application is being made on behalf of a child under the age of 13, all persons named on this form should confirm that the information that has been supplied in this application is correct and you are the person to whom it relates or acting on behalf of.

I certify that the information provided on this form is correct to the best of my knowledge and that I am the person to whom it relates. I understand that North Bristol NHS Trust is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.

I confirm that I am legally authorised to act on behalf of the data subject. I understand that North Bristol NHS Trust is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.

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