Subject Access Requests (SAR) – How to make a request

Subject Access Request

Wye Valley NHS Trust holds data about individuals. This can be within health records, emails or specific software. The Data Protection Act 2018 gives the public to view or receive copies of the information that an organisation holds about them.

You can use this form to ask to see a copy of personal data that we hold about you, in line with data protection legislation.

You can also use this form to ask to see the records on behalf of someone else, as long as you are legally allowed to act on their behalf. This includes:

Making a request for a child
Making a request for someone that you have power of attorney for.

You should fill in all fields that apply to you.

Are you making a request for yourself, or on behalf of someone else? Yourself Someone else

Section 1: Details of the person this request is about (the 'Subject')

Please tell us the details below about you, or the person you are applying on behalf of, so that we can check for the information we may hold:

Title:

Surname:

Forename:

Former surname:

Date of Birth:

Gender:

Contact number (daytime):

Email address:

Home address incl. postcode:

NHS Number (if known):

Getting as much information as possible helps us find the information you want. If you/the subject has been known by a different name or has lived at a different address during the time span of your enquiry, please give details below:

Section 2: Written authority to act on behalf of the person you are making the request for

you are acting on behalf of the subject, please tell us the details below. We need to know what gives you the authority to act on their behalf, so please state your relationship with them, for example, parent, solicitor, or holder of power of attorney.

Full name:

Relationship with subject:

Contact Number:

Email number:

Address:

Section 2: Written authority to act on behalf of the person you are making the request for

This section is only to be completed if applying on behalf of someone else.

Section 3: Proof of identity

Applying for yourself

You are applying for yourself, we need to see:

one document confirming your name, from Group A, below
one document confirming your address, from Group B, below

A. Documents that confirm your name:
- Full driving licence
- Passport
- Birth certificate
- Marriage or civil partnership certificate
- NHS identity badge
B. Documents that confirm your address:
- Utility bill
- Bank statement
- Credit card statement
- Benefit book
- Pension book

Applying on behalf of someone else

You are applying on behalf of someone else, we need to see:

One document confirming your name, from Group A, below
One document confirming the name of the person you are applying on behalf of, from Group A, below
One document confirming your address, from Group B, below
One document confirming the address of the person you are applying on behalf of from Group B, below
All documents needed to show that you have the authority to access the records, from Group C, below.

A. Documents that confirm your name:
- Full driving licence
- Passport
- Birth certificate
- Marriage or civil partnership certificate
- NHS identity badge
B. Documents that confirm your address:
- Utility bill
- Bank statement
- Credit card statement
- Benefit book
- Pension book
C. Documents that confirm you are allowed to act on behalf of the person you are making the request for:
- Health and Welfare Lasting Power of Attorney
- Court of Protection Order appointing you as a personal deputy for the personal welfare of the Subject
- Full birth certificate of child
- Full certificate of adoption
- Parental responsibility order
- Signed declaration from the subject

This list of acceptable identification is not exhaustive. Please contact the Subject Access Request team for clarification if required.

We may get in touch with you for further information.

Section 4: Helping us to find the information

The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g. leg injury following a car accident)

Requested Records Please provide me with a copy of all records held Please provide me with a copy of records between the dates specified below Please provide me with a copy of records relating to the incident specified below Please provide me with a copy of records relating to the condition specified below

Details

Please tick the box if you would like to receive all x-rays relating to your request

Section 5: Where you would like the copies of your information to be sent

Our preferred method of delivery is via email. Any documents sent will be password protected and sent securely.

If you would like to get your information by post, please note that information posted by special delivery will need a signature upon receipt.

Please tell us where you would like your information sent:

I am the Data Subject and would like my information sent to my email address given in Section 1. I understand that by ticking this that I agree for information to be sent securely through NHS.net. I am the Data Subject and would like my information posted to my home address given in Section 1.

I am acting on behalf of the Data Subject and would like the information sent to the email address given in Section 2. I am acting on behalf of the Data Subject and would like the information posted to the address given in Section 2.

Section 6: 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 13, everyone named on this form should endorse it 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 proof of authority as detailed in Section 3.

Knowingly or recklessly obtaining or disclosing personal data is an offence under data protection legislation. By endorsing this form, you are giving agreement that your personal data (or that of the person you are acting on behalf of) can be shared within Wye Valley NHS Trust in order that we may process your request and provide you with the information sought.

Your personal data will be kept in accordance with Wye Valley NHS Trust’s Retention and Destruction procedures.

Name of Data Subject:

Name of person making a request on behalf of the subject:

Your checklist Is your contact information correct? Have you completed all the relevant sections? Have you uploaded acceptable identification? Have you endorsed the form?