APPLICATION FOR ACCESS TO RECORDS

I am applying under the Data Protection Act 1998 to have sight of all the medical records held by the partnership at Newburn Surgery concerning:

Full Name.....................................................

Date of birth........................NHS number (if known)...................................

I understand that there will be a charge for this service unless I wish only to see the paper record and there has been an entry made within the last 40 days. *I also request further information from the medical records, for which I understand there is charge. I have set out below details of this request:

Signed..................................................Date...................

Name.......................................................................

Address...................................................................
..................................................................................
..................................................................................

* Delete this sentence if not applicable