CONSENT FORM TO BE SIGNED BY THE PATIENT (PAST OR PRESENT) FOR THE RELEASE OF INFORMATION UNDER THE ACCESS TO HEALTH RECORDS ACT 1990 AND DATA PROTECTION ACT 1998 Under the requirements of the Data Protection Act 1998 (which superseded the Access to Health Records Act 1990), the PRACTICE must obtain your consent before supplying information contained in your medical records Patient’s Name: Date of Birth: Address:
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Post Code: ………………Telephone Number: ……………………………….. To: Name of GP: ………………………………………………………….. Address:
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Post Code: ……………….Telephone Number: ………………………………. I understand my rights under the Data Protection Act 1998 (which superseded the Access to Health Records Act 1990) I agree to the information contained in my records being disclosed to:Name ………………………………………………………… Address ………………………………………………………. Date …………………………………………………………… Information to be disclosed (delete as appropriate) 1. Full Medical Records 2. Registration details 3. Part of my Medical Records (please specify dates and details) ……………………………………………………………………………….. Signed: …………………………………………………………. Name in Block Capitals: ……………………………………… Date ……………………………………. Documents needed for verification of identity. You will need to provide either a driving licence with photograph or a passport and if thee are unavailable your birth Certificate together with a utility bill