Subject Access Requets

Section 1: Details of the individual for whom the request relate
Postal Code
Date of Birth Click or tap to enter a date.

NHS Number (if known)
Contact Telephone Number

In order, to protect your information, we are unable to respond to a request unless we have confirmed your identity. Please provide one form of identification and one proof of address. If you are posting copies to us, please ensure these are appropriate certified, alternatively please attend the practice with original documents
Documents that can be used as proof of Identity:
1. Current signed passport
2. Residence permit issued by the Home Office
3. EU or Swiss national identity photo-card
4. Valid UK photo-card driving licence (full or provisional)
5. Valid armed or police forces photographic identity card
6. Photographic disabled blue badge
7. Citizen card

Documents that can be used as proof of current address (must be dated in the last six months):
1. Recent original utility bill (i.e. gas, electric, water, telephone - not mobile)
2. Hospital Appointment Letter
3. Council tax bill (valid for current year)
4. Bank, building society or credit union statement or passbook
5. Recent original mortgage statement from recognised lender
6. Current council/housing association rent book or tenancy agreement
7. Notification letter from Department for Work and Pensions / HM Revenue and Customs confirming your right to benefit or state pension

Section 2: Whose personal data are you requesting?
Please tick () which of the following applies:
I am the patient named in section 1 (please proceed to section 3)
I have a signed letter of authority to make this request. (please enclose a copy of singed authority)
I have parental responsibility for the patient who is under the age of 16 (please enclose a copy of proof of parental responsibility i.e. parental responsibility order issued by the Court or a copy of the Childs full birth certificate)
Please note: that you do not have an automatic right to your child’s data, and decisions will be made on the relevance of release of data to you. In the UK a child aged 13 years or older in most circumstances will be required to consent to the release of their data.
I have been appointed through a Lasting Power of Attorney to act on behalf of the patient (N.B. proof must be enclosed before the application can be processed i.e. a copy of the sealed document)
I am the deceased patient’s Personal Representative (proof must be enclosed before the application can be processed i.e. Grant of Probate or proof that you are the Executor of the Will)
Other Reasons (please outline)

If you are not requesting access to your own personal data, please provide the following information about you:
Full Name
Postal Code
Date of Birth Click or tap to enter a date.

Contact Telephone Number
Relationship to individual for whom you are requesting data:

Section 3: What data are you requesting?
Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification or objection.
Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.

Section 4: Declaration
I declare that the information given in this form is correct to the best of my knowledge and that I am entitled to apply for access to the records referred to under the terms of the General Data Protection Regulation 2016, Access to Records Act 1990 or the Mental Capacity Act 2005.
Please check the information you have provided and sign below:
Full name of Applicant

Signature of Applicant


Please return this form and the documents we have asked you to provide to Meddygfa Tywyn Bach.

For Office Use Only:
Identification Document/ Proof of Address Documnents Provided:
Indentification verified by:

Where the individual making the request is a representative of the patient a copy of relevant authorisation/ entitlement is attached: YES/NO

Please complete this form is you wish to:
• Access your personal data.

• Request the practice restrict the processing of your data
Your right to restrict data processing only applies in the following limited circumstances:
 There is a query about the accuracy of personal data we hold and only for a period to enable us to verify its accuracy
 The processing is lawful but instead of deletion you wish to restrict its use
 The information held about you is no longer needed for its original purpose
 You have objected to us processing the personal data, in which case processing can be restricted whilst we verify the processing required and our basis for doing so overrides your objection.

• Request to practice to rectify data held

• Request the practice to erase data held about you

Your right to have data erased only applies in the following limited circumstances:
I. Your personal data is no longer required for the purposes it was originally collected

II. The basis for processing your data is consent and you have withdrawn consent

III. The basis for processing your data is for our legitimate purposes, but our reason does not override your interests

IV. Personal data is being processes for Direct Marketing purposes and you object to that processing.

V. We have processed your personal data unlawfully

VI. There is a legal obligation to erase data for example a court order

VII. Data is being processes to offer certain digital services to a child

In most cases, the practice does not process your data or relay on any of the limited circumstances that would allow data to be erased. The Practice is required to ensure it keeps your records in line with the Public Records Act 1958, for public health purposes, including to ensure that you are provided with the correct healthcare treatment.

• Object to the processing of your personal data.

Your right to object to processing only applies to the following types of personal data:

Type of Processing
Right to object
Direct Marketing (including Profiling)
You have an absolute right to object
Processing we carry out based on legitimate interest or in the public interest or under official authority You can object at any time on grounds relating to your situation. We do not have to comply if we have legitimate grounds for the processing

Processing that we carry out for scientific or historical research or statistical purposes (except where the processing is necessary to carry out a task for public interest reasons You can object at any time on grounds relating to your situation. We do not have to comply if the processing is necessary for the performance of a task carried out for public interest reasons

You do not have to use this form; however, it will help us deal with your request more efficiently if you do.
You can also use this form, if you are making a request on behalf of someone else, however in such instances we will ask you to provide evidence of your entitlement to act and receive information (please ensure you complete section 3) or will seek authority from the individual for whom you have made the request.
You will not be charged for a copy of your records. However, the Practice can charge a “reasonable fee” when a request is manifestly unfounded or excessive, particularly if it is repetitive. We will therefore change a reasonable fee to comply with requests for further copies of the same information.
If you have any queries relating to your request, please contact the practice.

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