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Friday 23 June 2017
Derbyshire Healthcare NHS Foundation Trust
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Application form to request access to your own mental health record

Strictly confidential once completed

This form may be used if you wish to:

  • send us your request using email or
  • type in the information and then print off to post to us.

 

Please enter as much information as you can because this will help us to deal with your request as quickly as possible. The boxes will expand as you type into them.

» Indicates required fields

Request access to your own mental health record

Personal Details

Gender »
If you have an answerphone, are you happy for us to leave messages if necessary?

Confidentiality

We always do our utmost to maintain the confidentiality of our patients’ records. Unless you are currently an in-patient on one of our wards, we will require you to send us proof of identity by attaching or enclosing a copy of one of the following: Medical Card - Drivers Licence - Birth Certificate - Passport - a letter from DWP/Jobcentre; plus a copy of a utility bill showing your current home address.



If you are sending us paper copies in the post please indicate whether you would like us to returned them to you

Details of records requested 

Please provide as much information as possible, but we realise it may be difficult to remember everything accurately. It would be helpful if you could tell us the type of record you are wanting to access; some examples are:  medical/consultant’s file, in-patient nursing, day service, occupational therapy, physiotherapy, community team, child and adolescent, learning disabilities.

Our fees as set by the Data Protection Act 1998

Copies will be charged at a maximum of £50 Viewing only on Trust premises will be charged at a maximum of £10

I would like to be informed of the exact amount of your fee before the information is released to me. Please confirm.

There will be no charge if you are: 

• currently under our care or have been within the past 12 months  
• you are in receipt of benefits. 

We will require a copy of your current benefit payments.  You can either scan a copy and attach it to this form, email it to us or post us a paper copy.

I am a current patient or have been in the past 12 months »
Are you enclosing a copy of your current benefit payments? »

How would you like to receive any information we are able to release to you?

How would you like to receive any information we are able to release to you? »
Paper copies would be posted to you using Royal Mail's Special Delivery which requires a signature on delivery. Would you like us to contact you to arrange a specific day for delivery when we have completed your request?
Do you wish to view your record with a health professional on Trust premises? »
 

If you have any queries or need help with completing your application please do not hesitate to contact us either by telephone or by email:

Direct dial: 01332 623760  Switchboard: 01332 623700 ext 33760

Once completed you can either email your form attaching any relevant documents or post to us:

e-mail: dhcft.accesstoahealthrecord@nhs.net 

Postal address:

Access to a Health Record
IM&T and Records
Kingsway House East
Kingsway site
Derby, DE22 3LZ