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Data Subject Access Request

Required fields are marked with an asterisk (*).
*Please note - This is not a mandatory form but will assist us in dealing with your data subject access requests more efficiently.
Please provide your details below
*I would like to request a copy of my medical records, please tick the most appropriate option.

(Records will be emailed to you via the email address you have provided above)

Shifnal & Priorslee Medical Practice will require you to upload two forms of ID to allow us to proceed with your request.
  • 1 x Photo ID
  • 1 x Proof of Address
Disclaimer, please read carefully

I understand there is no fee for a data subject access request, only in exceptional circumstances.

I am aware that the records provided to me will be only from my electronic medical records, unless I state otherwise.

I am aware that this information will be provided to me within one month from Teldoc receiving this request. If there is a delay, Teldoc can extend this to two months, but I will be informed, with an explanation, why this extension is necessary.

I understand I will need to provide one form of photo ID and one form of proof of address if I am collecting paper copies of my records. This is to ensure Shifnal & Priorslee Medical Practice conforms to the Data Protection Act.
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Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

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