Access to the Health Records of a Deceased Patient (1)

Section 1: Personal Details of Applicant

Please fill in this section as fully and accurately as you can with the personal details of the person requesting the information.

Name

Address

Email

Telephone

Mobile number

Section 2: Personal Details of Patient

Please fill in this section as fully and accurately as you can, with the personal details of the person this access request is about. This will help us trace the personal information you need.

Patient Name

Date of Birth

Maiden, Previous or Other Name

Section 3: Scottish Ambulance Service Records Required

If this request relates to an ambulance attendance (incident) please provide the following information.

Date of incident

Time of incident

Address/Location of Incident

Nature of incident

Information requested

If this request relates to any other record held by the Scottish Ambulance Service please provide as much information as possible below to help us trace the information you need.

Section 4: Declaration

Please select one of the two options below

I am the patient’s personal representative and attach a copy of the confirmation of my appointment (Grant of Probate, Letter of Administration or the Patient’s Will).

Please upload your document here

I have a claim arising from the patient’s death and wish to access information relevant to my claim and attach documentation to prove this (a copy of the patient’s birth, death or marriage certificate).

Please upload birth, death or marriage certificate here

I confirm that the information I have given is correct and that I am entitled to apply for access under the conditions of the Access to Health Records Act 1990. *

Consent for storing submitted data *

Yes, I give permission to store and process my data

Section 1: Personal Details of Applicant

Section 2: Personal Details of Patient

Section 3: Scottish Ambulance Service Records Required

Section 4: Declaration

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