Data Request

Please answer the questions below which will determine which form of request is required and the information we will need.

Are you: *

The client requesting your own data (Subject Access Request)
Requesting access to someone else's data (Subject Access Request / Access to Health Records)
A public body requesting information on somebody else’s data? (Police, Fire Service, NHS, Local Authority etc.) (Previously known as a Section 29)
A journalist or member of the public requesting organisational data? (Freedom of Information Request)

Your Data

You have a right to be told whether we hold any information about you, and a right to be provided with a copy of that information within 30 days. In order to do this please answer the following questions carefully and supporting documentation.

You will need:

- Proof of your identity (such as Driving Licence or Passport with photo)
- Proof of your current address (such as Utility or Bank Statement in last 3 months)

If you can’t provide this information, please call us for advice on 0300 330 2940 and do not complete this form.

Name *

First

Last

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

NHS Number / Focus Reference Number

(if known, should be on any letters from us)

Confirm Email

What information do you require? *

Please provide as much detail as possible to prevent any delays in processing your request.

Is there a timeframe to consider?

This will help us locate this.

Would you like your information sending to a third party, another person or company? *

Please provide details of who & where to send your information.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Confirm Email

Please upload Proof of ID & Proof of Address

Click or drag files to this area to upload. You can upload up to 3 files.

Max of 3 files, no more than 5MB each. Photographs are accepted.

Signature *

You can sign using your computer mouse or a touch screen device. By signing, you are confirming the above details are correct to your knowledge.

Accessing someone else's data

Is the individual deceased? *

As part of the Access to Health Records Act 1990 usually you will only be able to access the deceased person’s health or social care record if you’re either:

- A personal representative (the executer of the administrator of the deceased person’s estate)
- Someone who has a claim resulting from the death (this could be a relative or another person) Only information directly relevant to a claim will be disclosed.

If possible, please ask the individual to compete this online form themselves from question 1 and they will be able to request us to send you the information directly.

If this is not possible you will need to provide evidence of:

- A Lasting Power of Attorney for Health and Wellbeing for the individual
- Power of Attorney

What information are you requesting? *

What is the reason you require this information? *

Your Name *

First

Last

Your Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Your Email *

Confirm Email

Your Relationship to Individual *

Upload Document Evidence *

Click or drag files to this area to upload. You can upload up to 3 files.

As mentioned above, please provide evidence of Lasting Power of Attorney (for Health & Welfare), Power of Attorney or any other documentation detailing your authorisation to have the requested data.

Signature *

Data Subject (Individual)

Name *

First

Last

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

NHS Number / Focus Reference Number

(if known, should be on any letters from us)

Public body request under Data Protection Act 2018 / Schedule 2 Part 1 Para. 2 or Para. 5 Data Protection Act 2018 (previously S29 Data Protection Act 1998) / Annex C Request

If you complete this online form it will trigger a digital approval process for efficiency - a copy will be sent to you to request/forward that email to your Authorising Officer to forward onto our focus.data@nhs.net email address. If this will not be possible please download our electronic form for signature outside of this process.

The police and other public bodies can request access to personal information held by local authorities for specified purposes. These types of request include Schedule 2 Part 1 Para. 2 or Para. 5 Data Protection Act 2018 and 2013 Protocol, Annex C information disclosure requests.

They can ask for information if it's about:

- prevention or detection of crime
- the apprehension or prosecution of offenders
- assessment or collection of tax, duty or imposition of a similar nature.

The Act:

- does not give an automatic right of access to information
- states that public bodies can assess the merits of requests and decide whether or not to apply the exemption

See the Information Commissioners Office guidance about exemptions. It includes reasons we must take into consideration when deciding whether to release information to relevant authorities.

Requester / Your Details

Name *

First

Last

Job Title *

Organisation *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Telephone Number

Email *

Confirm Email

Data Subject (Individual) Details

Name *

First

Last

Date of Birth//

Current or Last Known Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Other identifying information e.g. previous address, other names the data subject is known by, NHS number etc.

What information do you require? *

Reason for requesting disclosure. Include what you intend to do with the information and how long you will retain it: *

Please state how non release of the information will prejudice your investigation *

Declaration and Authorisation

The authorising officer must be of the rank of police inspector or higher, or for other ‘relevant bodies’ a senior officer/manger. In the case of an inspector not being available at your location, we will accept an email from an inspector (or higher ranking officer) attaching this paperwork and confirming their approval.

Declaration

I certify that:

- Information requested is compatible with the stated purpose (section 4) and will not be used in anyway incompatible with that purpose
- I understand information given on this form is correct
- I understand that if any information given on this form is incorrect, I may be committing an offence under Section 170 Data Protection Act 2018

Signature *

IMPORTANT: You will receive a copy of this form via email and you will need to forward this onto your Authorising Officer to forward to focus.data@nhs.net to approve.

Request public data under the Freedom of Information (FOI)

Please direct your query to the NHS North East Lincolnshire Clinical Commissioning Group (CCG).