Consent for Proxy Access to GP Online Services

A proxy user is a user that is allowed to process medical requests on behalf of another patient.

If you wish for another online user to have access to your records or grant them permission to speak to Woodseats Medical Centre on your behalf for things such as such as requesting prescriptions, booking appointments and accessing your medical records and information then you will need to set up this person as a ‘proxy user’.

If you have a child under the age of 12 you can request proxy access to your child’s medical records. When your child reaches 12 years old the proxy access will be reduced to only allow you to make appointments on their behalf and repeat prescription requests. Your child will then need to give consent for any further information to be shared. At the age of 16 proxy access will cease unless your child does not have capacity to manage their own healthcare
If the patient does not have capacity to confirm proxy access then the access will be forwarded for approval by the GP
Proxy application will not be accepted from third party organisations such as insurance company or solicitors.

Please ensure you have carefully read the NHS Proxy Access Guide prior to applying.

Patient consent form for another person to access their health records

Section One - Patient details

Patient’s Details (The person whose records another individual(s) is to be given access to)

First name(Required)

Surname(Required)

Date of birth(Required)

Address(Required)

Telephone number(Required)

Email address

Section Two - Granting proxy access

Granting proxy access(Required)

I, the patient give permission to my GP Practice (Woodseats Medical Centre) to give the representatives stated on this form, proxy access to my medical records as indicated within this form

I reserve the right to reverse any decision I make in granting proxy access at any time.

I understand the risks of allowing someone else to have access to my health record

I have read and understood the information provided above

Section Three - Representative details

Details of person to be given access to the above patients records

Full name(Required)

Relationship to patient(Required)

Telephone number(Required)

Address(Required)

Please detail below if the above access is to be limited in any way (e.g. only for test results, only for making or cancelling appointments or only for a specific time period)(Required)

Please use this box if there is a further representative you wish to have access to your records

You may receive a telephone call to confirm this access request from a member of our administrative staff; this is to ensure any requests are made with the knowledge of the individual and to safeguard individuals. Access can be denied by the surgery should a member of the clinical team feel this request has not been made with the patients best interests at heart, this access can be revoked by the surgery at any point.

Electronic Signature:(Required)

Date(Required)

Consent for Proxy Access to GP Online Services

Patient consent form for another person to access their health records

Section One - Patient details

Section Two - Granting proxy access

Section Three - Representative details

Helpful links

Further Info