Subject Access Request Form

If you would like to request information from your medical record or for a child you have responsibility for, please complete this form.

Last Updated: 30/07/2020

Important Information

• The Waterloo Practice collects, holds, and processes certain personal data about our patients (“data subjects”). As a data subject, you have a legal right, under EU Regulation 2016/679 General Data Protection Regulation (GDPR) to find out about our use of your personal data as follows: • Confirmation that your personal data is being processed by us; • Access to your personal data; • How we use your personal data and why; • Details of any sharing or transfers of your personal data; • How long we hold your personal data; • Details or your rights under the GDPR including, but not limited to, your rights to withdraw your consent to our use of your personal data at any time and/or to object to our processing of it. • As Data Controllers we must ensure that only the minimum/necessary data is released. We therefore ask that you be specific as to what you need in your request • We will respond to all subject access requests within one calendar month of receiving this signed form and will aim to provide all information required to you within the same period. If we require more information from you, or if your request is unusually complicated, we may require more time and will inform you accordingly • The requested information can be supplied as either a password protected email attachment, password protected files on a CD or a paper printout (CD / printout would need to be collected from the surgery). Unfortunately post is not a safe method by which to send patient records • In order to protect your personal information, proof of ID (and where it is for a child, relationship) will be required on collection of the information • The security of the information as supplied is the responsibility of the person making the request • No fee is payable under normal circumstances. We reserve the right to charge a reasonable fee for requests that are manifestly unfounded, excessive, or repetitive. Such charges will be based only on the administrative cost that we will incur in order to respond. • You do not have to use this form and may instead write to us

Patient details







Details of request




Description of your request

Please include dates where possible and as much information as possible to help us locate the information you need. if you require the information following a request from someone else/a company please provide us with this information and if possible a copy of the request.


Declaration

By submitting this form you confirm that you are the data subject named in this Subject Access Request. We cannot accept requests in respect of your personal data from anyone else, including members of your family.