SUBJECT ACCESS REQUESTS

Data Protection

Subject Access Request (SAR)

Application Form

 

 

Request for access to Personal Data under the General Data Protection Regulation (GDPR) and Data Protection Acts 1988-2018.

Please complete all parts of this form in full. No fee is chargeable for requests made to access medical files, unless exceptional circumstances apply, in which case we would advise you.

 

Part 1 – Details of Data Subject (Your Details)

 

 

Your details (in block capitals):

 

Name: ______________________________   Date of Birth _______________________________     

 

Surname__________________________________

 

Address:__________________________________________________________________

 

__________________________________________________________________________

 

Contact Phone Number:  ______________________________________________________

 

*E-mail Address _____________________________________________________________

 

*Only complete if you would like the medical reports securely e-mailed to you.

 

 

Part 2 – Details of Request

 

Help Us to Help You!

 

To assist us in locating the data you are requesting, please include as many specific details as possible in relation to your interactions with us in the past.

 

Please tell us the relevant period of time or timelines involved, particular report or incident.

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

_________________________________________________________________________________

 

 

 

Part 3 - Declaration

 

 

 

Signature of Requester: _____________________________________________

 

 

Date: _________________________________

 

 

Please return the completed Form to the Centric Health Practice. This form can be hand delivered, posted or e-mailed.

 

Thank you for completing this form. Your request will be acknowledged in the next 7 working days and details issued within 30 calendar days of receipt.

 

A copy of our Privacy Statement is available at: https://www.centricgp.ie/privacy-statement/

 

 

 

 

FOR OFFICE USE ONLY

Date of receipt                                                 

 

Acknowledgement issued

Medical reports issued