Opt In Prospective Access Request Form

SHIRLAND MEDICAL PROSPECTIVE ACCESS TO MEDICAL RECORDS REQUEST FORM

From the 1st of November 2023 patients who are registered with SystmOnline or any other NHS App can have access to their prospective medical record from 1st November onwards or date of registration whichever is later. This includes their consultation information, test results and documents e.g. hospital letters.

You can still access information about your repeat prescriptions, main diagnoses, test results and access appointment booking as usual through the SystmOnline Website or App, the Airmid App or the NHS App even without this prospective access feature.

If this can meet your needs, you may continue with this without any of the risks full prospective access may have.

You may prefer not to have prospective access in case of the following:

Harm from exposure through premature access to upsetting investigation results or documents without adequate preparation or an opportunity for the GP or hospital doctor to review these with you in a supportive environment.
Risks to those that may be under pressure to release their records to another person or organisation. e.g. a controlling partner or family member. (Coercive Control Risk).
If you are concerned about NHS records security and ability of others to fraudulently access this.
Risk of unintended misinterpretation of information through medical jargon and acronyms.
Disclosure of harmful third party information.

The practice will review all requests for prospective online access. Patients will be required to complete this form before access is granted if deemed appropriate. It should be noted that following NHS guidance some patients who fall into certain groups where there is potential for risk or harm, access will be withheld. Please see our website for further information.

Opt In Prospective Access Request Form

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email Address

Essential to access online services

Home Telephone Number

Mobile Telephone Number

Please read and agree with each statement (please tick or state ‘Yes’ to all that apply). If access is granted to my full medical record:

I am responsible for the security of the information that I see or download

Yes

If I choose to share my information with anyone else, this is at my own risk

Yes

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

Yes

If I see information in the record that is not about the patient I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential

Yes

Thank you for completing this form. Your request to view your full medical records will be reviewed by the practice. You will be informed of the practices decision once this review has taken place within 28 days.