RFI

Patient Information being requested

Please enter the details of the patient information being requested.
If you are not the patient, you will be asked to enter your details on the next page.

Complainant Code

Person Search

link id

Hospital Number

First Name / Surname

NHS Number (if this applies to a patient)

Title

Date of Birth

Patient Deceased

Date Died. If this query concerns a deceased patient, another process is followed

Ethnicity

Type of Person

Address

Post Code

Telephone

Person Requesting the Patient RecordsMore

Please attach a copy of the patient’s written consent/legal documentation authorising you to request information on the patient’s behalf, which can be done at the bottom of the form before submitting. Note: For other NHS Organisations, please provide the name of your organisation, and your contact details, i.e., email address and telephone number.

Requester Code

Person Search

Link ID

NHS Number

Title

First Name / Surname

Company Name

Hospital Number

Date of Birth

Person Deceased

Date Died

Ethnicity

Select the option which best describes you

Address

Post Code

Telephone

Your Company Reference Number

Your Job Title

Reporter

Person Reporting

The field above is for the Staff Lookup

Staff Id

Surname

First Name

Job Title

Job Status

Organisation

Site

Department

Directorate

Contact No.

Ethnicity

Email Address

Contact Details

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

On Behalf of (Staff)

Staff Id

Surname

First Name

Job Title

Job Status

Organisation

Site

Department

Directorate

Contact No.

Ethnicity

Email Address

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

Request DetailsMore

Please answer as fully as possible. The fields in orange are mandatory and MUST be completed for this form to be saved.

Type of Request

Date Received

Method Received

Time Received

Request Date

Response Due Date

Acknowleged

Summary (Brief Details)

Hospital Site

Response Format Required

Response Date

Extension Reason

Handler

Source

Estimate Of Time (hrs)

Estimate Of Time (mins)

Status

Request wide location info

Organisation

Locality 2

Locality 3

Site

Site Type

Department

Specialty

Locality 1

Locality 2

Please detail the information being requested

Please click the +New button for each additional type of record being requested.

Specialty (if known)

record	unique	DPA Type	Additional Info.	Del.

Please provide any other information that will assist with processing this request

Attachments and Documentation

The Trust needs 2 proofs of identification - 1 needs to be photographic ID e.g. passport, driving licence and 1 proof of address dated within the last 3 months e.g. utility bill, bank/credit card statement. If requesting on behalf of a patient, please provide a copy of their written and signed consent (their ID is not required when consent is provided) .

Add Attachments

Document	Date Added	Time Added	Entered By	Delete

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Workflow /

Submit Request