PATIENT PERSONAL DATA REQUEST FORM

PATIENT PERSONAL DATA REQUEST FORM
This form is designed for former patients requesting access to personal data that ACLS Training Services Limited t/a Codeblue has processed as part of providing medical services at events.
Personal Details
Full Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Format: (000) 000-0000.
SelfParent/GuardianLegal RepresentativeOther
Patient Age:*
Important Notice Regarding Consent for Patients Aged 16 and Older:

Please be aware that, in accordance with the General Data Protection Regulation (GDPR), the Data Protection Act 2018, and the guidelines issued by the Pre-Hospital Emergency Care Council (PHECC), individuals aged 16 and older are considered capable of managing their own data protection rights. The PHECC specifically emphasizes the importance of respecting the autonomy and decision-making capabilities of young adults in the context of pre-hospital and emergency care settings. As such, if you are a parent, guardian, or legal representative requesting access to the personal data of a patient who is 16 years old or older, it is mandatory for the patient to provide their explicit consent for the release of their data to you.

This requirement ensures that the privacy rights of young adults are respected, giving them control over their personal information. To proceed with your request, you may either direct the patient to complete this data request form themselves or, in exceptional circumstances where direct consent is not feasible, provide detailed information regarding these circumstances along with any legal documentation that supports your authority to act on behalf of the patient without their direct consent. Our team will review this information carefully and determine if the request can be processed in accordance with legal and regulatory requirements.

Document Upload for Legal Authority:

If you are unable to obtain direct consent from the patient due to exceptional circumstances, please use the document upload section provided below to submit any legal documentation that supports your authority to act on behalf of the patient without their direct consent. This may include, but is not limited to, court orders, legally recognized power of attorney, or other relevant legal documents that confirm your role and authority. Our team will review these documents as part of the data request process to ensure that all actions are compliant with legal standards and protect the rights of all parties involved.
Document Upload for Legal Authority:*

Cancelof
Patient Identification Upload:

In order to further ensure the security and accuracy of the data request process, it is essential that valid government-issued identification for the patient is submitted along with this form. Please upload a clear copy of the patient’s identification, such as a driver’s license, passport, or other government-issued ID.
Patient Identification Upload:*

Cancelof

Event Details
Name of Event where Treatment was Received:*
Date of Treatment*

DayMonthYear
Date
Request Details
Please specify exactly what data you are requesting:*
Purpose of Request:*

Verification of Identity

To help us process your request securely and ensure the authenticity of your personal data, please upload a copy of a valid drivers license or passport.
Driver's LicensePassport
File Upload*

Cancelof

Patient Details
Patient Full Name:*

First NameLast Name
Patient Date of Birth:*

DayMonthYear
Date
Consent and Declaration
By signing below, you consent to ACLS Training Services Limited trading as Codeblue to process your personal data as detailed in this form. This includes collecting, storing, and using your information strictly for the purposes specified in your data request. You confirm that all information provided is accurate and you understand your rights regarding your personal data, including the right to withdraw consent at any time. Please sign below to validate this request.
Signature*

Clear
Date Signed*

DayMonthYear
Date
Should be Empty:

PATIENT PERSONAL DATA REQUEST FORM

Personal Details

Event Details

Request Details

Verification of Identity

Patient Details