GP Consent Form

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

DOB(Required)

Preferred Phone Number(Required)

Name(Required)

Your GP Name

GP Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Your specialist doctors’ names and addresses(Required)

To assist us with your referral, we may wish to write to your doctor to request medical information about you (your doctor being your GP, family doctor or in the case of hospital treatment, your hospital specialist). Innovate Healthcare will keep information provided on a confidential basis and any advice given to your employer/prospective employer will be expressed in terms of fitness to work. We will inform you if we have made a request. We need your written consent to request a report under the terms of the Access to Medical Reports Act 1988, Access to Health Records Act 2018 and access to Personal Files and Medical Reports (Northern Ireland) Order 1991. You have certain rights. You can refuse consent if you wish. If you do give consent you have the right to see the report/medical records before it is sent to Innovate Healthcare Ltd if you wish. If you opt to see the report/medical records, you must ask your doctor to see it within 21 (twenty-one) days of the date it was requested. Please contact the surgery/hospital if this is the case. If you have not made contact within the 21-day period, the report/medical record will be sent to Innovate Healthcare Ltd. Please note it is your responsibility to contact them if you wish to see it. When you have seen the report/medical record from your doctor/s you have the right to withdraw your consent to release it to Innovate Healthcare LTD if you wish. If you consider any part of the report/medial record to be incorrect or misleading, you can ask your doctor to amend accordingly. If your doctor declines, a statement of your views can be submitted as an additional letter. During the 6 months after we have received the report/medical record you may ask your doctor to see a copy. Your doctor can charge a reasonable fee to cover the cost of a personal copy. If you wish to see the report in the future as you are able to under the terms of the Access to Health Records Act 2018 and Data Protection Act 2018, please contact your doctor. There may be a charge for this. Although rarely done, your doctor may withhold part or all of the report/medical record. This is when disclosure would cause serious harm to your health, or compromise other people’s confidentiality, health or safety. Your doctor will notify you in this event any you will have the right to see any remaining part of the report/medical record.

Please choose your preference by ticking the relevant box below for both of the following statements(Required)

I do give permission to my doctors to release a medical report/records to Innovate Healthcare Ltd

I do not give permission to my doctors to release a medical report/records to Innovate Healthcare Ltd

Signature

Print Name

Date