Subject Access Request Form (SAR)

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:

Name

Prefix First Surname

Former Surname

Former Surname Optional

Date of Birth

Gender

NHS Number (if known)

Contact Number

Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City Postcode

Are you are making the request on behalf of someone else?

Yes

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

This section should only be completed if you are making the request on behalf of someone else.

If you are not the subject, but 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.

Name

Prefix First Last

Relationship with the subject

Contact Number

Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City Postcode

Proof of Identity

Applying for yourself

If 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

Applying on behalf of someone else

If 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 certificate
NHS Digital 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

We may get in touch with you for further information.

Please tell us which copies of documents you are providing:

A: Confirmation of Name

B: Confirmation of Address

C: Third Party confirmation

Upload your documents

Drop files here or

Max. file size: 100 MB.

What information do you require?

Please tell us if you want information on

Full medical records

Partial medical records

Please give details:

Declaration

Your checklist

Is your contact information correct?

Have you enclosed acceptable identification?

Have you given your consent on this form?

Have you completed all the relevant sections?