This form is to be used if you wish to obtain a copy of information held by BPAS which relates to you.  Please note that we can only supply copies as all original documents form part of the medical records which need to be retained by BPAS.

Please print and return your completed application form and identification to:
BPAS Client Services Department, Orion House, 2 Athena Drive, Tachbrook Park, Leamington Spa, CV34 6RQ, or clientservices@bpas.org 

Our contact information:		Telephone:       0345 365 5050	
If you have any queries regarding the completion of this form, please contact us as above.

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Section 1:  Details of the person the request is about (‘the subject’)
In order to protect the privacy of the individual whom this request is about and in line with the requirements of the Data Protection Act, BPAS is keen to ensure we locate the records and information only relating to the person of this request.  Please supply the information outlined below.

Full Name:                                                                                     Date of Birth:  	

Current home Address (Inc. postcode):  	

Telephone Number:                                                                        Email Address:  	 

If the above-named person was known by a different name or lived at a different address during the period(s) to which the information required relates, please give details below:

Name(s):   	 

Address(s):   	

Section 2:  If you are making the request on behalf of somebody else
We need to know your details and what gives you the authority to make a request on behalf of somebody else.

Name:                                                                                     Date of Birth:  	

Home Address (Inc. postcode):  	                                      Telephone Number:         

Relationship with the person who the request relates to (‘the subject’):  	 

Section 3:  Proof of Identity

If you are making the request for yourself:
Please provide a copy of identification, in the form of a driving licence, your passport, birth certificate, Identity card or any official letter from Revenues & Customs. (Do not send original documents).

Please confirm which type of identification you are enclosing:_______________________________
If you are making the request on behalf of somebody else - please provide the following:
•	An item of identification (driving licence, your passport, birth certificate, Identity card or any official letter from Revenues & Customs).  
•	A copy of ‘the subjects’ identification (driving licence, your passport, birth certificate, Identity card or any official letter from Revenues & Customs).  
•	A document to show that you have the authority to access the records, e.g., Signed declaration from ‘the subject’, Court of Protection Order. 

Please confirm what documents you are enclosing:_______________________________

Section 4:  What information do you require?

Please detail exactly what information you require from your record.  This will help us to respond promptly to your request. If you think you may require further information you can submit a further request (there are no fees).  

*    Ultrasound images 

*    Discharge letter (which includes the date and type of procedure, contraception, medication)

*    Full (paper) medical record

Section 5:  Helping us to find the information
Please provide further details that may help to locate the information you are seeking.

Name of BPAS clinic(s) attended, or location(s):  
Date(s) of attendance:
BPAS reference number:  
Password /safeword (provided at the time of the initial booking call):

Section 6:  Declaration

I confirm that the information that I have supplied in this application is correct, and I am the person to whom it relates, or I am acting on behalf of the Data Subject and will enclose the relevant proof of authority.     Knowingly or recklessly obtaining or disclosing personal data is an offence under data protection legislation.  

Signature:                                                                                       Date:  	
	     NB: Please do not Type your name in the ‘Signature’ field