Application Form form for Copy of Medical Records Details of the Record to be accessed:Patient Full Name:Date of Birth DD slash MM slash YYYY Untitled OptionalFull Address (including postcode)Phone Number OptionalEmail Optional Please choose one of the following options: I confirm that I am the above named patient I am requesting this information on behalf of the above named patient Please note – the information will be released to the Data Subject (Patient) onlyMedical Records Options:I wish to obtain a copy of my medical record: Option 1 – Part of the records between specific dates Option 2 – The entire record Option 3 – A second copy of which has previously been provided by KAMP From Date DD slash MM slash YYYY To Date DD slash MM slash YYYY Date of Previous Request DD slash MM slash YYYY Information that was provided Full Record Specific Date Range I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the General Data Protection Regulation 2018. I understand that copies under option 1 and 2 will be provided free of charge, unless the volume of material is considered excessive, in which case a charge may be levied, or in extreme cases, KAMP may legitimately refuse this request. I understand that if charges are appropriate, KAMP will inform me of these in advance, and that I can then decide not to proceed, or to proceed in a different way that avoids the charge.Signature
