Subject Access Request Online Form
Please read important information below.
Under the Data Protection Act (DPA) 2018 and the General Data Protection Regulation (GDPR) you are entitled to obtain from Medicana confirmation as to whether we are processing personal data concerning you, as well as to request details about the purposes, categories and disclosure of such data. Medicana has 30 days to meet this requirement once you have submitted your photo identification.
You can use this form to request information about and access to any personal data we hold about you. After you have filled in the below information you will receive an email to the email address you have provided containing a link to upload your photo ID. Please ensure the ID is a clear photo of your full identification and not just a picture of you. These images are for viewing purposes only and are not for diagnostic reviews. If a medical professional/consultant needs access to your images to provide ongoing care they can request for these to be send directly to them via IEP by contacting us on 01962 587821.
Personal details
1. Full name
*
First Name
Last Name
2. Contactable telephone number
*
-
Area Code
Phone Number
3. Date of birth
*
-
Month
-
Day
Year
Date
4. Email address (this is where we will send the link for you to upload your photo ID)
*
example@example.com
5. Full home address
*
6. Previous address if changed since treatment started
7. Please provide specific details of data requested
*
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Family representative
8. Are you acting as the family representative of a person requesting the data? (please note, we may still need to contact the person where proof of authorisation or identity has not been provided.)
*
Please Select
Yes
No
9. If you have answered yes to question 8, what is the family representatives name?
First Name
Last Name
10. If you have answered yes to question 8, what is the family representatives telephone number?
Please enter a valid phone number.
11. If you have answered yes to question 8, what is your relationship to the patient?
12. If you have answered yes to question 8, what is the family representatives full address?
13. If you have answered yes to question 8, what is the family representatives email address?
example@example.com
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Legal Statement
14. I confirm that I give my consent for Medicana to liaise with any other bodies that form part of the investigation into my request. I confirm that the information I present on this form is correct and accurate and I understand that to falsify any information may render me liable to prosecution.
Please Select
I confirm
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Subject Access Request form guidance.
Please read before submitting form.
1. The form above gives Medicana the right to disclose records pertaining to the name as detailed in the Personal Details section of the consent form once sufficient photo identification has been provided.
2. The Personal Details section of this form identifies the recipient of the records, this must be completed at all times. It also provides Medicana with the personal details required to identify the records requested. In addition, a legal statement must be signed in all cases in the Legal Statement section.
3. The representatives of the person requesting data for family member section is for any family members who are requesting on behalf of the family member. This part can be ignored if nobody else forms part of the requested records.
4. In order to ensure that the records are provided to the correct person applying for them, Medicana needs a form of evidence about the identity of the person applying. The evidence must be supplied via the email that has been sent with instructions to upload the photo ID. A clear copy of a passport or driving licence (photo id) is required to be uploaded.
5. If you have any questions or need to contact anyone about any part of this form, please email us at DPO@medicana.co.uk
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Photo ID
In order to ensure we are giving access to the correct person for their medical records, please provide us with a copy of photo identification. Please be aware this can be either your passport or driving license.
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