Application Form for Online access
Application form for online access to the practice online services
(See notes on next page to consider prior to seeking access)
Surname
Date of birth
First name
Address
Postcode
Email address
Telephone number
Mobile number
I wish to access my medical record online and understand and agree with each statement (tick)
1. I will be responsible for the security of the information that I see or download and I have read the information on the next page
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2. If I choose to share my information with anyone else, this is at my own risk
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3. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible
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4. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
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5. 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.
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Signature Date
For practice use only
Patient NHS number
Identity verified by (initials)
Date
Practice computer ID number
Documentary evidence provided
Method used
Vouching □
Vouching with information in record □
Photo ID and proof of residence □
Authorised by
Date access created
Date
Date patient informed – or message added to clinical notes due to SMS message
Additional notes
Reason for refusal if record access is refused after clinical assurance.
Assured by (initials)
Ref : RCGP Toolkit https://elearning.rcgp.org.uk/mod/book/view.php?id=13455&chapterid=767
Please note:
- It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. Access can also be gained on some phones using fingerprints or Face ID – please consider this.
- If you have concerns about this, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.
- If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.
- The practice may not be able to offer online access due to a number of reasons such as concerns that it could cause harm to physical or mental health or where there is reference to third parties. The practice has the right to remove online access to services for anyone they feel it could harm or be put at risk.
Key considerations
Forgotten history
There may be something you have forgotten about in your record that you might find upsetting.
Abnormal results or bad news
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.
Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.
Coercion
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.
Misunderstood information
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.
Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.