COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST



Applying for Access to your Countess of Chester Hospital NHS Foundation Trust Health Records

Please read these guidance notes before completing your application form.

Introduction

Most patients, or their representatives, have the right under the General Data Protection Regulation 2016, within certain circumstances, to access records that the Countess of Chester Hospital NHS Foundation Trust holds about them. This includes both paper records and records which may be held on computer. This is known as a ‘subject access request’ (SAR).

Who can gain access?

People who can apply for access include:

• the patient themselves

• someone acting on the patients behalf if:-

o they have written authorisation from the patient (in the case of a relative, carer or legal representative etc.)

o permission from the Court

o they are the parent or guardian of the patient where the patient is a child

• Someone with a claim arising from the death of the patient

Anyone making a request is entitled to:

• A description of the information held, what it is used for, who might use it, who it may be passed on to and an explanation as to where the information was gathered from

• Information on retention periods for the information held

• Request rectification or erasure of processing

• Raise an objection to the processing altogether

Will I have access to all of my health records?

The Countess of Chester NHS Foundation Trust will only be able to give you access to the records that it holds about you, and also to explain any part of the record that you do not understand. However, if the health care professional who has been treating you decides that seeing your records might put your health at risk, you may only be shown part of your record or your request may be declined.

Access may also be declined if someone other than the healthcare professional has added information and could be identified from the records.

Do I have to pay to see my health records?

A copy of the requested information will be provided free of charge. However, the Trust can charge a ‘reasonable fee’ when a request if manifestly unfounded or excessive, particularly if it is repetitive. The Trust may also charge a reasonable fee to comply with requests for further copies of the same information. The fee would be based on the administrative cost of providing the information.

How do I apply for access to my health records?

If you would like to see your records you will need to complete the ‘Application Form for Access to Health Records’ and provide a copy of proof of identification that has a photograph on it.

Two forms of ID must be provided, one from each of the lists below:

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 within 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 |

If you would like an electronic version of the application form please download the form from

The completed Application Form along with a copy of your personal identification document/s can be returned by email to: cochlegalservices@

Or, alternatively post to:

Legal Services Department

Countess of Chester Hospital NHS Foundation Trust

Liverpool Road

Chester, CH2 1UL

Application forms can be obtained from the Trust internet/intranet site or by contacting Legal Services on 01244 365301.

The Countess of Chester NHS Foundation Trust, can correspond with you by E-mail, at your request. Emails are generated using the Trusts secure e-mail facility however once transmitted over a public network this may not be secure. The Trust cannot guarantee the security of the information transmitted by email to personal email addresses.

Any paper copies will be sent to your home address. If you live in the UK the records will be sent by recorded delivery. If you live outside of the UK then recorded delivery is not possible and you should be aware that the Trust cannot accept liability for the loss of records in a foreign postal system.

Please ensure that you complete the required information in full, taking extra care to ensure your email address is correct, the trust can accept no responsibility for incorrect or out of date information provided.

What will happen after I apply?

All applications are acknowledged by the Legal Services Department and are then forwarded on to the most appropriate health professional or manager within the Trust. They have responsibility for deciding whether you can access your full records.

If access is granted, then you will be contacted by the Legal Services Department to arrange a mutually suitable time to view the records or if you have requested copies of your records then this information will be collated and sent out to you in the requested format.

How long will this take?

A response to your application should be received within one month of receipt of your completed application from and any associated information and documentation that is required.

The month will begin upon receipt of:

• Fully completed Application Form for Access to Health Records

• Copy of proof of identity containing a photograph

• Sufficient detail to locate the information requested

This gives the team time to locate the specific information requested and the permission of the doctors who cared for you when you attended the hospital. Every effort will be made to get them to you as soon as we can.

If the request is complex or numerous then we may request an extension of time but we will inform you of this and explain why the extension is necessary.

Providing the required documentation to support your application.

If you wish to view your health records you will be required to provide personal photographic identification i.e. a passport or driving licence with photograph when the viewing takes place.

If you are collecting copies you will also be asked to provide this documentation when attending to collect your copy records. If you nominate someone else to collect the copies on your behalf they will also be required to provide personal photographic proof of their identity. They must also provide a letter of authorisation signed by you unless you have already authorised them to act on your behalf when completing the application form.

How to request access to a health record on behalf of another person.

There are circumstances where it is necessary to make an application on behalf of another person. This includes:

• a parent or carer applying on behalf of a child under the age of 16

If a person has parental responsibility for a child under the age of 16 then they may apply on their behalf. However, sometimes it may be necessary to give consideration to the views of children under this age when an application is received. See the authorisation section in the application form.

• a patient who has the capacity, wishing to authorise another person to apply on their behalf

If the treating health professional or manager responsible for reviewing the application considers that the patient does not have capacity to understand the application, then the decision to disclose information will be at their discretion.

• a person has been appointed to administer a Lasting Power of Attorney (which must include the health and welfare category)

If you have been appointed to administer a Lasting Power of Attorney (which must include the health and welfare category) you may have limited access to the patient’s health records when necessary. The same applies to a person appointed to make decisions about such matters by the Court of Protection in England and Wales. See the authorisation section of the application form.

Accessing the record of a person who is deceased

If a patient is deceased there is still a duty of confidentiality to that person.

In accordance with the Access to Health Records Act 1990 only the Personal Representative or someone who has a claim arising out of the patient’s death is legally entitled to apply for disclosure of any health records which may support a claim.

The Personal Representative is deemed to be the Executor of the Will or someone who has been granted probate. Evidence of this status must be enclosed with the application.

At all other times a voluntary disclosure will be considered by the Trust providing there is a valid reason to support the application. A statement to this effect must be enclosed with the application.

What if I disagree with my records?

The General Data Protection Regulation (2016) gives individuals rights in respect of personal information that the Trust holds about you. These are:

• To be informed of how, where and why we use your information

• To request access to your information

• To request that your information be corrected it if is inaccurate or incomplete

• To request that your information be deleted or removed where there is no reason for us to continue to process it

• To ask us to restrict the use of your information

• To ask us to copy or transfer your information from one IT system to another in a safe and secure way, without impacting the quality of the information

• To object to how your information is used

• To challenge any decisions made without human intervention (automated decision making)

Should you have any queries regarding the use of your information, please speak to our Head of Information Governance on 01244 362113

How are my records used to help me?

The team of health professionals caring for you keep records about your health and the care you receive from the Countess of Chester Hospital NHS Foundation Trust.

These are important and help to ensure that you receive the best possible care.

Your records are used in the following ways to guide and administer the care you receive:

• To ensure that health professionals have accurate and up to date information about your health care needs

• To ensure that full information is available should you see another health professional or are referred to another part of the National Health Service NHS)

• To ensure that there is a good basis for reviewing the quality of care you have received

Whilst preserving your confidentiality, your records can also help us to help you by:

Assisting with teaching and training of healthcare professionals (but you can choose whether or not to be involved personally)

Assisting with health research (if you need to be personally involved with the research, you will be contacted to see if you are willing to participate. You will not be identified without your agreement)

How is the confidentiality of my records maintained?

All staff working for the Countess of Chester Hospital NHS Foundation Trust

have a legal duty to maintain the highest level of confidentiality of patient information.

Sometimes, you may be receiving care from other people as well as the Countess of Chester Hospital NHS Foundation Trust and we may need to share some information about you with them, so that we can all work together for your benefit. Anyone who may receive this confidential information about you from us is also under a legal duty of confidence.

We will only give your relatives, friends and carers information if you give us permission to do so.

In certain circumstances, we are required by law to report information to the appropriate authorities. This information is only provided after formal authority has been given by a qualified health professional. For example:

• notification of new births

• where we encounter infectious diseases which may endanger the safety of others (e.g. meningitis or measles, but not HIV/Aids)

• where a formal court order has been issued

Our guiding principle is that of confidentiality.

What If I have a complaint about accessing my records?

If you feel that you have not been fairly treated or that your application has not

been dealt with appropriately, then you can write to us or complete one of our patient feedback cards and send to the following address:

The Patient Advice and Liaison Service (PALS)

Countess of Chester Hospital NHS Foundation Trust

Liverpool Road

Chester, CH2 1UL

e-mail: cochpals@

Telephone: Freephone 0800 195 1241 select option 2

If you are still unhappy with the outcome of your enquiry you can report your concerns to:

Information Commissioners Office

Wycliffe House

Water Lane

Wilmslow

Cheshire, SK9 5 AF

Telephone: 0303 123 1113

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