аЯрЁБс>ўџ *,ўџџџ)џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСq ПJbjbjt+t+ * AAH џџџџџџ]rrrrrrr††††8О Ъ$†ЎЖsuuuuuu$dєX b™r™frrfff"rrs††rrrrsfђfXŽћhrrsю л­ЗџР††$BcSOMERSET LOCAL MEDICAL COMMITTEE & SOMERSET LAW SOCIETY Form of Consent to the Disclosure of General Practitioner Medical Records Under the Data Protection Act (1998) To : Dr………………………..and Partners Address: (a) Full name of Patient …………………………………………………………… Date of Birth …………………………………………………………… Current Address …………………………………………………………… Address at time of incident …………………………………………………… Name and relationship if applying on behalf of a child under 16 …………… ……………………………………………………………………………………………………. This application is made because I am considering A claim for clinical negligence against your practice Yes / No A claim for clinical negligence against another party Yes / No namely …………………………………………….. A different action Yes / No Nature of event/injury in question ………………………………………… …………………………………………………………………………………….. And approx date(s) …………………………………………………………. Request for disclosure Please will you send copies of my medical record to Messrs …………………Solicitors Address: ………………………………………….. ………………………………………….. I wish to obtain copies of my electronic and paper records under the terms of the Data Protection Act (1998) and according to my requirements as follows: Important: Delete sections which do not apply. If you do not specify, all of your records will be sent 5. Date of Records 1.Please send copies of the whole content of my records. 2. Please send copies of my records from date ………………. 3. Please send records relevant only to the following injuries or conditions ………………. …………………………………………………………………………………………….. Disclaimer I understand that the copies of records may be sent to a lawyer and not a doctor I understand that my family doctor has no control over what happens to copies of records once they leave his or her premises I understand that the information in my records may be made available to my opponent (and their solicitors and experts) in the claim which I am making, and that my solicitor may be required to make them available to the court. I understand that it is my responsibility to arrange for the storage or destruction of the copies of records at the conclusion of the case I understand that only records that would directly damage my health if disclosed or those which contain confidential information about another person will be withheld by the doctor unless I have specified to the contrary Signed …………………………………….. Date …………………… Name in Full (block capitals) …………………………………………………………………… Please note that the request may only be signed on behalf of a patient by a parent or guardian where the patient is a child under 16. 8ƒЈЉ­ЩЪгедџ3ѕz‘ДЕОзо§   4 N ‰ ™ AJ§їѕёюёююёюёюёюёюшфшфшфѕюёюсюCJ6CJ 56CJCJ5CJ5 5>*CJCJ!8ƒЈЉЩЪгде 23[\Žежўџ23t§ћљљљѓљљљюљщхщљщљщљсљљюљм & F„а„h & F & F ЦрР!8ƒЈЉЩЪгде 23[\Žежўџ23tuЕЖбвєѕ)*MNќіѓ№эшхтпйжаЭХТКЗЏЌЉІЃ›˜’‡„~vskhebыќџџ§џџ§џџC§џџ  D§џџf§џџ  g§џџ‚§џџƒ§џџУ§џџ  Ф§џџ ўџџ ўџџ8ўџџ  9ўџџ:ўџџbўџџcўџџЊўџџ  Ћўџџмўџџ  нўџџџџџ  џџџ -џџџ 2џџџ cџџџ dџџџeџџџnџџџoџџџџџџџџџЕџџџ Шџџџ$tuЕЖбвєѕ)*MNyz‘прќџД§јє№№јьч§ь§т§чьоо§§§§§§§§„h & F & F„h„а„а & FNyz‘прќџДЕ  5 n o Ѕ І § ў ( ) 4 †  ц q N O P { | ‰ К Л ACDEFGHIJњїяььщщщщщчччччх Оќџџ  Пќџџ ъќџџ 0ДЕ  5 n o Ѕ І § ў ( ) 4 †  ц q N O P { | ‰ К Л AC§§§ћї§ї§їїї§ћ№№№№№э§§§§§§ы§$$ & F„аCDEFGHIJ§§§§ћћћ(&P А‚. 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