Proxy access request

Patient Details

Full Name:

Section 1 – Responsibility

Please tick that you agree:

I will be responsible for the security of the information that I see or download

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

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

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Signature:

Date:

Section 2 – Granting Proxy Access

I give permission to my GP practice to give the following people proxy access to the online services indicated in section 3 below.

I reserve the right to reverse any decision I make granting proxy access at any time.
I understand the risks of alloiwng someone else to have access to my health records.
I have read and understand the information leaflet provided by the practice.

Name of person:

This is the name of the person you wish to give access.

Name of person:

This is the name of the person you wish to give access.

Signature of Patient:

Date:

Section 3 – Proxy Access Level

Please grant the following access to my proxy/ies:

Ability to book appointments on my behalf

Online prescription management

Access to my medical records (this includes allergies, lab test reports, summarised documents since joining the surgery, immunisations, problems)

Signature of Patient:

Relationship of proxy user to patient:

Date:

Section 4 – Only for patients without capacity

I (patient), request for my GP to authorise proxy access to the following people.

I reserve the right to reverse any decision I make granting proxy access at any time.
I understand the risks of alloiwng someone else to have access to my health records.
I have read and understand the information leaflet provided by the practice.

Name of GP:

I agree to bring ID for myself to the surgery within 21 days to complete this proxy request.

Under 16’s – If there is no ID available a parent/carer can bring their ID in to vouch on your behalf.

Next Steps

The person you are granting proxy user status to must download, print and fill out Section 5 and 5.1 after you have filled out the appropriate sections above, and bring it with you to the practice.

Tell us whether you accept cookies

Patient Details

Section 1 – Responsibility

Section 2 – Granting Proxy Access

Section 3 – Proxy Access Level

Section 4 – Only for patients without capacity

Next Steps