Subject access request: NHS Resolution query

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Name (of form submitter)

First Last

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Email (of form submitter)

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SAR Form ref no (entry id)

Do you have any of the following?(Required)

Existing/closed claim with NHS

Practitioner Performance Advice case

Primary Care Appeals case

NHS Resolution HR or recruitment query

None of the above

Are you requesting data for:(Required)

Myself

Another person

Section A: Details of the data subject (Please complete YOUR details below)

Name (of data subject)(Required)

Title First Middle Last

Address(Required)

Correspondence address of the data subject

Telephone number (of data subject):

Email address (of data subject)(Required)

Professional Medical Registration Number (if applicable) e.g. GMC

Practitioner Performance Advice Case Number, or details about case (if any/known)

Claims Reference Number (if any/known)

Primary Care Appeals Reference Number, or details about appeal (if any/known)

Do you have any existing/closed claim against the NHS? (e.g. NHS Trusts, GP, or other)(Required)

Yes

Don't know

Details of information requested

Please describe the information that you believe we hold and to which you are seeking access. Please include dates for the information required.(Required)

If you can be specific about the information that you would like, it will assist us to locate it (if we hold it). If we require further details about the information that you are requesting, we will contact you. Please note: NHS Resolution DO NOT HOLD medical records (unless there is an existing claim), hospital appointments and medication details.

Section B: Identification

Identity documentation may be required in order for us to process your request. Please provide us with a copy of either your passport or driving licence, and a recent copy (within 6 months) of one utility bill showing your current residential address. Please complete the checklist below to indicate what you have enclosed with this form.

Please send a copy of your ID and proof of address to the following email: nhsr.foi@nhs.net

The copy identity documentation will be shredded once we have verified your identity.

As soon as we receive the required documentations we will start processing your request.

Section A: Details of person acting on behalf of the data subject

Please complete YOUR details below.

Your full name(Required)

Title First Middle Last

Your address for correspondence(Required)

Your telephone number

Your email address(Required)

Your relationship to data subject(Required)

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Do you have any existing/closed claim against the NHS? (e.g. NHS Trusts, GP, or other)(Required)

Yes

Don't know

Section B: Identification

Proof of authorisation will be required in order for us to process your request.

Please send a copy of the proof of authorisation (e.g. power of attorney, proof of authorisation with data subject's signature) to the following email: nhsr.foi@nhs.net

As soon as we receive the authorisation form we will start processing your request.

Section C: Details of the data subject (person to whom the information relates)

Name (of the data subject)(Required)

Title First Middle Last

Address (of data subject)(Required)

Correspondence address of the data subject

Telephone number (for data subject)

Email address (for data subject)(Required)

Professional Medical Registration Number (if applicable) e.g. GMC

Practitioner Performance Advice Case Number, or details about case (if any/known)

Claims Reference Number (if any/known)

Primary Care Appeals Reference Number, or details about appeal (if any/known)

Details of information requested

Please describe the information that you believe we hold and to which you are seeking access. (Please include dates for the information required.)(Required)