Please complete this form if you wish to:
Access your personal data. Request the practice to restrict the processing of your data
Your right to restrict data processing only applies in the following limited circumstances:
There is a query about the accuracy of personal data we hold and only for a period to enable us to verify its accuracy
The processing is lawful but instead of deletion you wish to restrict its use
The information held about you is no longer needed for its original purpose
You have objected to us processing the personal data, in which case processing can be restricted whilst we verify the processing required and our basis for doing so overrides your objection.
Request to practice to rectify data held Request the practice to erase data held about you
Your right to have data erased only applies in the following limited circumstances:
Your personal data is no longer required for the purposes it was originally collected
The basis for processing your data is consent and you have withdrawn consent
The basis for processing your data is for our legitimate purposes, but our reason does not override your interests
Personal data is being processes for Direct Marketing purposes, and you object to that processing.
We have processed your personal data unlawfully
There is a legal obligation to erase data, for example a court order
Data is being processes to offer certain digital services to a child
In most cases, the practice does not process your data or relay on any of the limited circumstances that would allow data to be erased. The Practice is required to ensure it keeps your records in line with the Public Records Act 1958, for public health purposes, including to ensure that you are provided with the correct healthcare treatment.
Object to the processing of your personal data. Your right to object to processing only applies to the following types of personal data:
Type of Processing
Right to object
Direct Marketing (including Profiling)
You have an absolute right to object
Processing we carry out based on legitimate interest or in the public interest or under official authority
You can object at any time on grounds relating to your situation. We do not have to comply if we have legitimate grounds for the processing
Processing that we carry out for scientific or historical research or statistical purposes (except where the processing is necessary to carry out a task for public interest reasons
You can object at any time on grounds relating to your situation. We do not have to comply if the processing is necessary for the performance of a task carried out for public interest reasons
You do not have to use this form; however, it will help us deal with your request more efficiently if you do.
You can also use this form, if you are making a request on behalf of someone else, however in such instances we will ask you to provide evidence of your entitlement to act and receive information (please ensure you complete section 3) or will seek authority from the individual for whom you have made the request.
Furthermore, you will not be charged for a copy of your records. However, the Practice can charge a “reasonable fee” when a request is manifestly unfounded or excessive, particularly if it is repetitive. We will therefore charge a reasonable fee to comply with requests for further copies of the same information.
Section 1: Details of the individual for whom the request relates
Title
Surname
Forename(s)
Address including Post Code
Date of Birth
NHS Number (if known)
Contact Telephone Number
In order, to protect your information, we are unable to respond to a request unless we have confirmed your identity. Please provide one form of identification and one proof of address. If you are posting copies to us, please ensure these are appropriate certified, alternatively please attend the practice with original documents (acceptable documents listed below):
Documents that can be used as proof of Identity:
1. Current signed passport 2. Residence permit issued by the Home Office 3. EU or Swiss national identity photo-card 4. Valid UK photo-card driving licence (full or provisional) 5. Valid armed or police forces photographic identity card 6. Photographic disabled blue badge 7. Citizen card
Please upload the relevant document as proof of identity
Documents that can be used as proof of current address (must be dated in the last six months):
1. Recent original utility bill (i.e. gas, electric, water, telephone - not mobile) 2. Hospital Appointment Letter 3. Council tax bill (valid for current year) 4. Bank, building society or credit union statement or passbook 5. Recent original mortgage statement from recognised lender 6. Current council/housing association rent book or tenancy agreement 7. Notification letter from Department for Work and Pensions / HM Revenue and Customs confirming your right to benefit or state pension
Please upload the relevant document as proof of address
Section 2: Whose personal data are you requesting?
Please select which of the following applies:
Other reason
If you are not requesting access to your own personal data, please provide the following information about you:
Full Name
Address to include postcode
Date of Birth
Contact Telephone Number
Relationship to individual for whom you are requesting data:
PLEASE NOTE: If you are not requesting access to your own personal data, we are unable to respond to your request until we also receive the following:
• Satisfactory confirmation of the identity of the person on whose behalf you are making this request. Please provide details outlined in section one.
• A copy of your legal authority to make this request. This may be a signed letter of authority, a power of attorney document or other legal document confirming you are their legal representative
Section 3: What data are you requesting?
Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification, or objection. Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.
I declare that the information given in this form is correct to the best of my knowledge and that I am entitled to apply for access to the records referred to under the terms of the UK General Data Protection Regulation (UK GDPR) 2016, Access to Records Act 1990 or the Mental Capacity Act 2005.
Please check the information you have provided and sign below:
Full name of Applicant
