Medical Information Request Form Template for England and Wales

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Key Requirements PROMPT example:

Medical Information Request Form Template

I need a Medical Information Request Form Template for our hospital's research department that allows us to request patient data for a clinical trial starting in March 2025, ensuring GDPR compliance and including specific consent mechanisms for research purposes.

Document background
The Medical Information Request Form Template serves as a standardized mechanism for requesting patient medical information in England and Wales. It is designed to ensure compliance with data protection regulations while facilitating efficient information exchange between authorized parties. This document is essential when medical records or specific health information needs to be accessed, whether for continuing care, legal proceedings, or insurance purposes. It incorporates all necessary elements required by UK GDPR and healthcare privacy laws, including patient consent mechanisms and data protection notices.
Suggested Sections

1. Patient Information: Basic identifying details including name, date of birth, NHS number, contact information and address

2. Requestor Details: Information about the person making the request, including full name, contact details and relationship to patient if not the patient themselves

3. Purpose of Request: Clear statement of the specific reason for requesting medical information, including intended use

4. Information Requested: Detailed specification of which medical information is being requested, including date ranges if applicable

5. Consent Declaration: Express consent section for information release, including data protection acknowledgments and GDPR compliance statements

6. Identity Verification: Requirements for proving identity and list of acceptable documentation

Optional Sections

1. Third Party Authorization: Additional section for when medical information is to be released to someone other than the patient, including legal authority verification

2. Urgent Request Section: Special section for expedited processing requests, including justification for urgency

3. Fee Information: Details of any applicable charges and payment methods for requests falling outside of free access rights

Suggested Schedules

1. Schedule 1 - Identity Verification Requirements: Comprehensive list of acceptable ID documents and specific requirements for verification

2. Schedule 2 - Fee Schedule: Detailed breakdown of potential charges for different types of requests and circumstances

3. Schedule 3 - Authority Forms: Standard templates for third-party authorization and power of attorney confirmation

4. Schedule 4 - Privacy Notice: Detailed information about how the provided information will be used, stored, protected and processed in compliance with GDPR

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Industries

UK GDPR and Data Protection Act 2018: Primary legislation governing how personal data, particularly sensitive health data, must be collected, processed, and stored in the UK. Provides framework for data protection principles and individual rights.

Access to Health Records Act 1990: Legislation specifically governing access to deceased patients' medical records and establishing who has rights of access to these records and under what circumstances.

Access to Medical Reports Act 1988: Legislation regulating access to medical reports prepared for employment or insurance purposes, including patients' rights to view, amend or withhold consent for such reports.

Mental Capacity Act 2005: Framework for making decisions on behalf of individuals who lack mental capacity, including provisions for accessing and managing medical information for such individuals.

Human Rights Act 1998: Incorporates European Convention rights into UK law, particularly Article 8 regarding right to privacy, which impacts medical information handling and sharing.

NHS Act 2006: Contains specific provisions regarding confidentiality and information sharing within the National Health Service framework.

Professional Guidelines: Includes General Medical Council (GMC) guidance on confidentiality, NHS Digital guidelines, and British Medical Association (BMA) guidance on handling medical information.

Common Law Duty of Confidentiality: Fundamental legal principle requiring medical professionals to maintain patient confidentiality, established through case law and professional practice.

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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