Subject Access Request Form

Application for access to records under the General Data Protection Regulations 2018, the subject access provisions of the Data Protection Act 2018 and the Access to Health Records Act 1990 Leicestershire Partnership NHS Trust provides integrated mental health, learning disability and community health services in a variety of settings. To help us locate the health records you require please provide as much information as possible.

Name*
Any other name(s) known by

For example previous surnames, or names the patient preferred to be known as
Current home address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Day time telephone number
Previous address (if applicable)
Date of birth

Day
Month
Year
NHS number (if known)
Hospital numbers (if known)
Please give any information about the health records you require, including services, locations and dates
Any other additional relevant information
Section B - to be completed by the person making the request
I declare that the information in this form is correct to the best of my knowledge and that:
- I am the data subject (the person whose records are being requested)
- I have been asked to make this application by the data subject
- The patient is under 13 years of age and I am acting in loco parentis
- The person is deceased (you will also be required to confirm your legal entitlement to access the records, e.g. personal representative of the deceased or you have a claim arising out of the death).
Name of person making the request
Email address (if you are happy to be contacted by email) or postal address (with postcode)
Day time telephone number
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Subject Access Request Form

Subject Access Request Form

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