ACCESS TO MEDICAL REPORTS ACT 1988

This is a summary of your principal rights under the Act, which is concerned with reports provided for employment or insurance purposes by a medical practitioner who is, or has been, responsible for your clinical care.

"*" indicates required fields

1. You may withhold your consent to an application for the report from a medical practitioner.

2. You may consent to the application, but indicate your wish to see the report before it is supplied. (You must make the necessary arrangements with the medical practitioner to see the report – it will not be sent to you automatically.)

3. If you request access to the report:

a. You have 21 days in which you will need to arrange with the doctor to see the report

b. Should you not arrange to see the doctor within 21 days, the doctor can send the report direct to the doctor

c. Having seen the report you can request, in writing, to amend anything which you consider to be incorrect or misleading. However, the doctor is not obliged to change anything. If the doctor refuses to amend the report, you may;

i. withdraw your consent for the report to be issued

ii. ask the medical practitioner to attach a statement of your opinion

iii. agree to the report being issued unchanged

NOTE: The medical practitioner is not obliged to show you any parts of the report which he/she believes might cause serious harm to your physical or mental health or that of others, or which would reveal information about the identity of a third party who has supplied the practitioner with the information about your health unless the third party also consents. In these circumstances, the medical practitioner will so inform you, and your access to the report will be appropriately limited.

4. You may consent to the application for the report but indicate that you do not wish to see the report before it is supplied. Should you change your mind after the application is made, notify the medical practitioner in writing, he/ she should allow 21 days to elapse after such notification so that you may arrange to have access to the report (if the report has not already been supplied before you change your mind).

5. Whether or not you decide to seek access to the report before it is supplied, you have the right to seek access to it from the medical practitioner at any time up to 6 months after it was supplied.

NOTE: Where a copy of the medical report is supplied to you, the practitioner may charge a reasonable fee to cover the cost of supplying it.
This form is to be completed in all cases by an employee before any request for a medical report is made by the Occupational Health Adviser to another doctor for the purpose of:

a. Assessing fitness to fulfill the job role;

b. Predicting future fitness to return to work;

c. Other.

Consent*

I understand my rights under the Access to Medical Reports Act 1988, and have read the summary of my principal rights under the Act.

a. I consent that Henrietta Vale, Occupational Health Adviser may provide in confidence a medical report about my fitness to work to management.

b. I consent that my own General Practitioner/Consultant may provide a medical report in strict confidence to the Henrietta Vale, Occupational Health Adviser.

c. I consent to Henrietta Vale, Occupational Health Adviser speaking to my GP/Consultant regarding my current medical condition if necessary

Consent

I DO

I DO NOT

Wish to have access to this medical report before it is provided by my own Doctor to Henrietta Vale, Occupational Health Adviser.

Name*

Title Forenames Surname

Gender

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone number

Name of General Practitioner

Surgery Name & Address

Surgery Name Address City State / Province / Region ZIP / Postal Code Country

Telephone Number

Name of Hospital Consultant

Surgery Name & Address

Surgery Name Address City State / Province / Region ZIP / Postal Code Country

Telephone Number

Signature

Signed Date*