Proxy access patient consent

Patient Details

Details of the patient for whom the request relates

Section

Details of person to be given access to this patient’s information

First name(s):

Surname:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Address, including postcode:

Relationship to Patient:

Relative, friend, carer etc.

Legal basis for proxy access:

Parental responsibility for a patient under 16 years

Lasting power of attorney

Carer or guardian

Other

Please specify:

Which online services do you wish to grant access to?

I wish to grant access to the following online services

Booking appointments

Requesting repeat prescriptions

Sending secure messaging

Access to detailed medical record

Proxy Access to records for family members who I care for with separate login details

Please select all that apply.

Parental proxy access for children

If you are requesting proxy access for a child, the practice must verify identity and parental responsibility. You will need to provide photo ID for yourself and the child (for example, passports). You must also provide evidence of parental responsibility, such as a birth certificate. If the child is aged 11 years or over, the child must also give their consent before proxy access can be granted.

Confirmation

I confirm that I have parental responsibility for the child named on this form and can provide supporting documentation, i.e. a birth certificate.

Child consent

I understand that if the child is aged 11 years or over, the practice will require the child’s consent before proxy access can be granted.

Consent

I wish to grant access to my online services and understand and agree with each statement

I have read and understood the information provided by the practice

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

If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible

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

If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible

If I see something in my records that I am unsure of and have not yet been contacted by the surgery, I will wait until usual opening times and not contact the out of hours or emergency services

Patient’s consent

I understand that this consent will remain in force indefinitely. However, my doctor may, at my request, override this authority to allow access to my medical records via Online Services at any time. 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 medical records.

Representative (proxy) consent

I will treat any information provided confidentially. I will not disclose information to a third party without agreement. I will only use the information in the person that I have proxy access for in their best interest.

Signature

Please enter your full name:

Date:

Proof of identity

Representative (proxy) identity

Maximum file size: 67.11MB

To register for proxy access, we need to verify your identity. Please provide the practice with 1 photo ID such as passport or drivers licence and 1 form of ID with your home address on such as a recent utility bill or bank statement.

If proxy access is being requested for a child, the practice will also require proof of the child’s identity (for example, a passport) and documentation confirming parental responsibility, such as a birth certificate.