This form is to be used if you wish to find out what information, if any, The Health and Social Care Information Centre (HSCIC) is holding or is processing that relates to you.
Please return your completed application form to:
email@example.com or Information Governance Department
The Health and Social Care Information Centre
4th Floor Vantage House
40 Aire Street
Role of the Health and Social Care Information Centre The Health and Social Care Information Centre (HSCIC) was established in law as an Executive Non-Departmental Public Body (ENDPB) on the 1st April 2013. Its remit was outlined in the Health and Social Care Act 2012 and the Governments information strategy for health and care in England. It is the trusted source of authoritative data and information relating to health and care. It supports the delivery of IT infrastructure, information systems and standards to ensure information flows efficiently and securely across the health and social care system to improve patient outcomes.
Section 7 of the Data Protection Act 1998 gives individuals the right to request access to personal records held on them by persons or organisations such as the HSCIC. This is known as a Subject Access Request (SAR).
Please refer to the following notes for guidance when completing this form.
Applying for your own records
Please complete the following sections:
1, 3 A and B, 4, 5, 6 and 7
Please note: section 1 b should only be completed if you currently or have previously worked for the HSCIC or one of its legacy organisations (see section 1b for further details), and you are requesting copies of your personnel records.
Making an application on behalf of the data subject
Please complete ALL sections.
Please note: section 1 b should only be completed if the person you are making an application on behalf of currently or previously worked for the HSCIC or one of its legacy organisations (see section 1b for further details), and you are requesting copies of their personnel records.
Please ensure you enclose copies of all relevant authorisation documents
Making an application on behalf of a child
Only an individual with parental responsibility, or a third party (eg solicitor) acting on their behalf can make a request on behalf of a child. If you have parental responsibility for a child in order to help us establish your relationship to the child, you must submit one or more of the following:
Full marriage certificate of parents (if details not shown on birth certificate)
Full certificate of adoption
Parental responsibility order
Court order assigning parental responsibility
Payment As a Data Controller of personal information, the HSCIC can charge a fee for dealing with a request for personal information under the DPA (Subject Access) (fees and miscellaneous provisions) Regulations 2000. There are special rules that apply to fees for access to manual health records (such as those records which fall under the Lloyd George envelope category). The charges are as follows:
Held electronically only: up to a maximum £10 charge.
Held in part electronically and in part on other media (paper, x-ray film): up to a maximum £50 charge.
Held totally on other media: up to a maximum £50 charge.
The HSCIC will charge 20p per sheet for photocopying plus the cost of postage up to the maximum charge.
You will be advised of the exact cost once the relevant information has been located.
If you have any queries regarding the completion of this form, please contact us on the number shown above.
Section 1: Details of the person the request is about (data subject) In order to protect the privacy of the individual whom this request is about and in line with the requirements of the Data Protection Act, the HSCIC is keen to ensure we locate the records and information only relating to the subject of this request. I would be grateful if you could supply the information outlined below.
Date of Birth:
NHS Number (if known)
Telephone Number (day):
If the above has been known by a different name or has lived at a different address during the period to which the information required relates, please give details below:
Name: From (date): To (date):
Name: From (date): To (date):
Section 1 b Please complete the following ONLY if you are requesting copies of personnel records, and you (or the subject) is currently or has previously worked for the Health and Social Care Information Centre (HSCIC) (including the NHS Central Register) or one of its legacy organisations (The NHS Information Authority, The Prescribing Support Unit or the Department of Health – Stats Division)
Name(s) of employing authority _______________________________________
Section 2: Written Authority If you are acting on behalf of the Data Subject (i.e. the person to whom the information is about) written authority is required. Please complete the details below. Also, please state your relationship to the data subject (e.g. parent/guardian, solicitor, holder of power of attorney, etc.)
Your full name
Contact telephone number
Email address ______________________________________________
Relationship to the subject:
Section 3: Proof of Identity It will be necessary to confirm the identity of all parties included on this form. Please supply a photocopy of one document from section A and B, and all relevant documents from section C with the application.
A. Confirmation of name1
I am providing the following types of identification, which are attached to this document.
A. Confirmation of name
B. Confirmation of address
C. Third Party confirmation
Section 4: What information do you require? Please detail here the information you require from the HSCIC
Section 5: Helping us to find the information Please use the space below to provide further details that may help to locate the information you are seeking. Please supply as much detail as possible such as:
Details of your (or if you are applying as a 3rd party details of the subjects) current and/or previous Primary Care Trust(s) which may assist us in locating the relevant personal medical records (as held by your GP).
For personnel records – names of individuals who you believe may hold personal data relating to yourself/3rd party
Any other details you may feel have relevance e.g. relevant dates, consultant name etc.
Section 6: Dispatch details
Please indicate where you would like your records dispatched to (please select one option):
I am the data subject and would like my records to be dispatched to my home address as detailed in section 1 above
I am acting on behalf of the data subject and would like the records dispatched to the address as detailed in section 2 above
I would like my records to be dispatched to my GP
GP Name ________________________________________________________
Section 7: Declaration 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 12, all persons named on this form should sign below.
I confirm that the information that I have supplied in this application is correct, and I am the person to whom it relates or I am acting on behalf of the data subject and have enclosed the relevant authority as detailed in section 3.
Person making a request of behalf of the data subject
Please note that information will be posted by special delivery which will require a signature upon receipt. However, if the Royal Mail are unable to deliver to the address given and need to return the documentation to the Health and Social Care Information Centre this will be returned by normal post (i.e. not under confidential cover).
Your Checklist Is your contact information correct?
Have you enclosed acceptable identification?
Have you signed the form?
Have you completed all the relevant sections?
1 Where there has been a change of name we will require evidence of the name for which the information is being sought e.g. a birth certificate will not be considered as evidence for searches on a married name.