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Request for the Completion of a Form, Letter or a copy of Medical Record

Forms and Letters

Please complete the information on the reverse of this form if you are requesting a form to be completed or a letter provided by a clinician. Please also submit with this document the form you require completing or your written request for a letter. These are usually completed within 28 working days, however, if there is a particular clinician that needs to complete the form the timescale may be extended.

There may be a charge for completing your letter or form. We will contact you once we have reviewed your request and inform you of the fee for your agreement prior to starting the work. 

Payment will need to be paid in advance prior to work being started. We accept cash, card and bank transfer. We DO NOT accept PayPal payments. Please ensure you have considered the fee prior to paying upfront. 

No refunds will be given if you decide after payment not to proceed as some work may have already been started.

Subject Access requests

If you are requesting information under the General Data Protection Regulations 2018. Access to your Medical Records (for example medical records, results and vaccination information), you will need to complete the reverse form and also attach your request for information.  There will be no charge for this information and it will be ready to collect within 1 month from the request date. There will be a charge for any subsequent copies of the same information.

Collection

A member of the team will inform you when this is ready to collect, if you have not heard anything after 20 working days please call 0116 2151105.

The information will only be released to the patient or their nominated party.  Please note we will not, under any circumstances release this information without the proper and correct Identification. If we are suspicious of anyone collecting information on behalf of another person we will withhold the information until the data subject has been contacted.

If you wish for some else to collect your information please fill in the form below and ensure that person brings in photographic identification (passport, driving licence, national ID card).

Non-NHS work form
Who is the Non-NHS work for?
Your details

Details of patient who requires Non-NHS work

Patients details
Please tick the relevant statements

Please upload relevant documentation

Maximum file size: 67.11MB

If you have selected other

Please select what work you would like carried out

GP letter

A form to be completed

Medical records

Please specify what part of your medical records you require

Online Access to medical records

If you have selected online access to full medical record when this has been completed you will be notified via call, SMS or email.

Other

Upon the completion of request how would you like to receive the documentation?

Agreement

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