Application for Information under the Data Protection Act 1998

Access to Health Records Act 1990

The Princess Alexandra Hospital
NHS Trust
Hamstel Road
Harlow
Essex CM20 1QX

Name of person making application:

Address if different to patient:

Telephone number:

Mobile Number:

Email :

DETAILS OF PERSON WHOSE INFORMATION IS REQUIRED

Relationship to the person making the application:

Patient Name:

D.O.B:

Address:

NHS Number:

PAH Hospital Number:

Copies of which records/x-rays do you require?

Reason for urgency if applicable:

Please note that if you require an x’ray cd only payment will be required prior to
processing your request.
Please make cheques payable to PAH NHS Trust and send to The Medico-Legal Dept or
if you wish to pay by card please contact our cashiers office on 01279 827362 for an
authorisation code.

Authorisation code_____________

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Please state below that you have the permission of the patient to make this application and
that you can supply ID, birth/death certificates, and or power of attorney papers as required?

PLEASE INDICATE BELOW THAT YOU UNDERSTAND THAT GIVING FALSE

INFORMATION MAY BE REPORTED AS FRAUD

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