Everest House Surgery

Everest Way, Hemel Hempstead, Herts, HP2 4HY

Telephone: 01442 500 164

Sorry, we're currently closed. Please call NHS 111

Online proxy access form

ONLINE ACCESS TO HEALTH RECORDS REQUEST

Name(Required)

First Last

Date of birth(Required)

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Mobile(Required)

Telephone number

Email(Required)

NHS number (if known)

Section 2: Record requested

I wish to have access to the following online services (please tick all that apply):

Booking appointments

Requesting repeat prescriptions

Access to my medical records

I wish to access my medical record online and both understand and agree with each of the following statements (tick):

I have read and understood the information leaflet provided by the organisation

I understand that I will automatically see any new information (prospective records) that is added to my healthcare record.

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the organisation as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the organisation as soon as possible

Patient signature(Required)

Date

Section 3: Consent to proxy access to GP Online Services (if patient has capacity)

Consent to proxy access to GP Online Services (if patient has capacity)

I, give permission to my GP practice to give the following person/people proxy access to the online services as indicated below in Section 5

I reserve the right to reverse any decision I make in granting proxy access at any time

I understand the risks of allowing someone else to have access to my health records

I have read and understand the information leaflet provided by the organisation

Patient signature(Required)

Date

I/We wish to have access to the health records on behalf of the above-named patient

Name

First Last

Date of birth

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Mobile

Telephone

Reason for access:

I have been asked to act by the patient

I have full parental responsibility for the patient and the patient is under the age of 18 and has consented to my making this request or is incapable of understanding the request (delete as appropriate)

Section 4: Consent to proxy access to GP Online Services (if patient does not have capacity)

I/We wish to have access to the health records on behalf of the above-named patient

Name

First Last

Date of birth

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Telephone

Mobile

Reason for access:

I/We have been appointed by the Court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so

I am/We are acting in loco parentis and the patient is incapable of understanding the request

I am/We are the deceased person’s personal representative and attach confirmation of my/our appointment (grant of probate/letters of administration)

I/We have written and witnessed consent from the deceased person’s personal representative and attach Proof of Appointment

I/We have a claim arising from the person’s death (please state details below)

Section 5: Proxy access online services available

I/We wish to have access to the following online services (please tick all that apply)

Booking appointments

Requesting repeat prescriptions

Access to my medical records

Section 6: Proxy declaration

I/We wish to access to the medical record online of the above patient and I/we understand and agree with each statement (tick)

I/We have read and understood the information leaflet provided by the organisation and agree that I/we will treat the patient information as confidential

I/We will be responsible for the security of the information that I/we see or download

I/We will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement

If I/we see information in the record that is not about the patient or is inaccurate, I/we will contact the organisation as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential

Patient signature(Required)

Date

Section 7: Proof of identity

Under the Data Protection Act 2018, you do not have to give a reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up. Please speak to reception if you are unable to provide this.

File(Required)

Max. file size: 128 MB.

File(Required)

Max. file size: 128 MB.

ADDITIONAL NOTES

Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form.

87000

Update your details

Test and result

Patient Participation Group

Friends & Family Test

Request a Sick Note

Home Blood Pressure Reading

Opening Times

Monday
08:00am to 01:00pm
02:00pm to 06:30pm
Tuesday
08:00am to 01:00pm
02:00pm to 06:30pm
Wednesday
08:00am to 01:00pm
02:00pm to 06:30pm
Thursday
08:00am to 01:00pm
02:00pm to 06:30pm
Friday
08:00am to 01:00pm
02:00pm to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Blood Test Booking - West Herts Hospital

Everest House Surgery

Online proxy access form