Access to medical Records by Proxy If you need to provide consent to proxy access to a patient’s medical records, please submit this form. Section 1 – Patient Details(This is the person whose records are being accessed)Name First Last Date of birth Day Month Year Preferred Contact NumberAdditional Contact Number: OptionalEmail address Optional Address Street Address Address Line 2 City Postcode Please confirm the following: The patient has the capacity to consent to grant proxy access. The patient does not have the capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest. I give permission to my GP practice to give the people listed in Section 3 proxy access to the online services as indicated below in Section 2.I reserve the right to reverse any decision I make in granting proxy access at any time.I understand the risks of allowing someone else to have access to my health records.I have read and understood the information leaflet provided by the practice.Declaration I confirm that I have read and understand the information above Patient Signature (PRINT full Name)Section 2 – Details of access requiredPlease tick proxy access required Online appointment booking Online prescription ordering Accessing details coded medical record Section 3 – Details of the representative(s) seeking proxy access(These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription)Representative 1 Name First Last Representative 1 Date of birth Day Month Year Relationship to patient Preferred Contact NumberAdditional Contact Number OptionalEmail address Address Street Address Address Line 2 City Postcode Would you like to add another representative? Yes No Representative 2 Name First Last Representative 2 Date of Birth Day Month Year Relationship to patient Preferred Contact NumberAdditional Contact Number OptionalEmail address Address Street Address Address Line 2 City Postcode Declaration I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1. Optional I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements I/we have read and understood the information leaflet provided by the Practice and agreed that I will treat the patient information as confidential. I/we will be responsible for the security of the information I/we see or download. I/we will contact the Practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement. If I/we see any information in the record that is not about the patient, or is inaccurate, I/we will contact the Practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential. Your Signature Representative 1Your signature Representative 2
