Hospice IOM Subject Access Request Form

Personal Details

Surname:

Forename(s):

Previous / alternative names:

Date of Birth:

YYYY

Address

NHS Number (if patient):

Other means of identification (copies of which should be attached if necessary):

Identification file upload:

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Contact Telephone Number and/or email address:

Are you the Data Subject (i.e. the person to whom the data relates):

Yes

If you are the data subject: please submit this form and COPIES of any evidence of your identity (e.g. Driving Licence, Passport).

Acting on behalf of the Data Subject

If you are acting on behalf of the data subject with their written or other legal authority, please state your relationship with the data subject i.e. parent, legal guardian or solicitor.

Please upload proof that you are legally authorised to obtain this information. The proof could be a letter of authority, letters or official forms addressed to you on behalf of the data subject.

Please state below what proof of authority you have enclosed (please tick):

Letter of Authority

Correspondence

Official Forms

Power of Attorney

Proof of Authority upload:

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Data Subject's Details (if different to those given in the section above)

Surname:

Forename(s):

Previous / alternative names:

Date of Birth:

YYYY

Address

NHS Number (if patient):

Relationship to Data Subject:

Specific Information Being Requested

Data subjects have the right to request ALL personal data relating to them, however, to ensure you receive specific data that is being sought and at the earliest opportunity, we ask that you provide us with a description of that data. Please be as specific as possible in your description of the data you would like to obtain, together with any other relevant information.

Long text

Declaration

I certify that the information given in this application form is true and that any attempt to mislead may result in legal proceedings against me.
I understand that it is necessary for the organisation to confirm my / the Data Subjects identify and it may be necessary to obtain more detailed information to locate the correct information.
I understand that the response period of one calendar month, as stipulated in the Act, will not commence until Hospice Isle of Man is satisfied upon these matters.

First Name:

Surname:

Signature

Date:

YYYY

Fees

Hospice Isle of Man will provide the information free of charge; however we reserve the right to charge a reasonable fee when a request is manifestly unfounded, excessive or repetitive.

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