Guidance on accessing patient records
Information about your personal treatment and care is confidential and will normally be something you will discuss with the healthcare professionals you meet. However, there may be other issues about which you would like further information or you may just want to have a copy of the information we hold about you.
Your right to request access to your personal records
The General Data Protection Regulation (GDPR) 2016 gives living individuals the right to request access to personal records held about them by organisations such as United Lincolnshire Hospitals Trust. This is known as a Subject Access Request (SAR). The GDPR requires the Trust to comply with requests for information within 1 calendar month.
Any individual can make a Subject Access Request (SAR). In addition, an individual may nominate a representative (such as a solicitor, relative or just someone they trust) to apply on their behalf. In this case, there must be a valid consent signed by the individual who authorises the release of information to the representative.
A person who has parental responsibility for a young child can request access to the child’s records. Release of records is usually only made in the best interests of the child. Children may apply themselves – where it is considered that the child has the competence to be able to understand the nature and implications of making a request. If they are considered competent, they should also be consulted regarding any request that has been made for their records by another individual, i.e. a person with parental responsibility. The competence of the child in respect of requests for records can be considered from the age of 12.
For mentally incapacitated adults a person may make a request on their behalf if they have been granted power of attorney or agent by a court to manage their affairs. The request must be made in relation to the management of their affairs and finances.
Request-for-Information-Form-2022
Access to deceased patient records
The Access to Health Records Act 1990 provides certain individuals with a right of access to the health records of a deceased individual. These individuals are defined under section 3 (1) (f) of the act as ‘the patients personal representative and any person who may have a claim arising out of the patients death’. A personal representative is the executor or administrator of the deceased person’s estate.
Due to the requirements set by legislation, we cannot release copies of records to the next of kin.
How to request access
If you wish to request access to patient records you will need to complete the Request for Information form and send this to the hospital site you received your treatment.
The contact details are:
Lincoln County Hospital
Access to Health Records
Health Records Department
Lincoln County Hospital
Greetwell Road
Lincoln LN2 5QY
Tel: 01522 573249
Pilgrim Hospital
Access to Health Records
Health Records Department
Pilgrim Hospital
Sibsey Road
Boston
PE21 9QS
Tel: 01205 445279
Grantham & District Hospital
Access to Health Records
Health Records Department
Grantham Hospital
101 Manthorpe Road
Grantham
NG31 8DG
Tel: 01476 464544
Email: accesstoinformation@ulh.nhs.uk
What documentation will I need to provide
In most cases we will require copies of two items of evidence of identity. For example: passport, driving license, utility bill, birth certificate.
Types of applicant and the evidence they need to provide
An individual applying for his/ her own records
Two copies of identity required. Please see the below list, one form of identification must be photo identification and the other evidence of a recent proof of address.
For example: passport, driving license, utility bill, birth certificate.
Someone applying on behalf of an individual
Two items of proof of the person’s identity and one item of proof of the representatives identity (see examples above)
Person with parental responsibility applying on behalf of a child
Proof of identity for each person with Parental Responsibility (see examples above).
As well as proof of your own identity, you will need to provide one of the following documents:
- The child’s birth certificate
- Parental responsibility agreement entered into by birth parents; or
- Copy of a Court Order giving parental responsibility (such as an adoption order).
If there are any Court Orders or restrictions to access in place, you will need to provide us with a copy of the order.
Power of Attorney/Agent applying on behalf of an individual
Copy of Power of Attorney plus one item of proof of the person’s identity and one item of proof of the representative’s identity (see examples above).
Deceased Records
Patients representative: for example executor or administrator of estate
Two forms of proof of identity (a form of photo ID and a proof of address) and evidence that they are either Executor of the Will or the Administrator of the deceased patient’s estate.
Evidence could be:
- Copy of the will/probate documents/Letters of Administration
Please give a short reason for requesting access to parts of the deceased medical notes and your relationship with the deceased.
(Please note that your request will not be processed without this information)
Person with a claim arising out of the patients death
Proof of identity and evidence of actual claim.
Evidence could be:
- Solicitors letter
- Insurance claim or letter
- Evidence of genetic problem-
Doctor’s or solicitor’s letter to support the request.
Exemptions to the release of personal information
In general, all the personal records you request will be released to you although there may be circumstances where certain information could be restricted.
These include:
- If it is considered that information in the records, if released, may cause serious harm to yourself or any other individual.
- Where there is personal information concerning another person contained within your records.
How will the information be provided?
In most cases, copies of the records will be made and sent to you (or you can collect the copies if you prefer). You may however prefer to view the records, in which case the Trust will arrange with you a suitable time and location for you to come in and view the records.
Will I be charged for access to the records?
Under GDPR, the trust cannot charge automatically for a request unless the information has already been provided to you in a previous request or the request is manifestly excessive. You will be advised of this at the earliest stage of the request.
If you are not satisfied with your response:
In the first instance, you should write to the team that handled your request explaining why you are dissatisfied with the response and asking for a review to be carried out.
If you remain unhappy and you wish to discuss further you can do this by writing to the Trust’s Data Protection Officer.
By post
Data Protection Officer
Information Governance Department
Robey House
Lincoln County Hospital
Greetwell Road
Lincoln
LN2 5QY
Email: ulh.dpo@nhs.net
Independent Advice
If you remain dissatisfied with the Trust’s response, you can contact the Office of the Information Commissioner – the body with responsibility for enforcing the Data Protection Act. The address is:
Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF
Tel: 0303 123 1113 (local rate) or 01625 545 745 if you prefer to use a national rate number Alternatively you can visit their website (www.ico.gov.uk) for further information about Subject Access Requests under the General Data Protection Regulation 2016.
Please note that the ICO does not support complaints or queries that have been made under the access to health records act 1990.
Requests for other health records: for example GP
If you require access to your primary care health record, the request should be made to the relevant GP, dentist, pharmacist, or optometrist. Records for secondary care records (now including community services records) should be made to the local acute, mental health, community service trust or social enterprise.
Further information
For further information please contact the access to health records offices via accesstoinformation@ulh.nhs.uk
Useful links and documents
Please see the below websites and resources that may be useful when applying for access to Health Records:
- Further information about Information Governance can be found on the Health and Social Care Information Centre website
- The Information Commissioner has produced a series of guidance about your subject access rights which can be found on the Information Commissioner’s Office website.