Adult consent to proxy access to GP online services

Section 1 – Patient Details

(This is the person whose records are being accessed)

Surname: *

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode:

Please confirm the following:

The patient has the capacity to consent to grant proxy access.

The patient does not have the capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest.

I give permission to my GP practice to give the people listed in Section 3 proxy access to the online services as indicated below in Section 2.

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 records.

I have read and understood the information leaflet provided by the practice.

Signature of Patient:

Date:

Section 2 – Details of access required

Please tick proxy access required:

Online appointment booking

Online prescription ordering

Accessing full medical record

Section 3 – Details of the representative(s) seeking proxy access

(These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription)

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1.

I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:

I/we have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential.

I/we will be responsible for the security of the information that I/we suspect that the account has been accessed by someone without my/our agreement.

I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement.

If I/we see information in the record that is not about the patient or in inaccurate I/we will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

Your signature(s)

Representative 1

Date

Your signature(s)

Representative 2

Date

Identification

Patient ID Required

2 original forms of identity from Appendix 1. One must be photo ID.

Representative/Proxy ID Required

2 original forms of identity from Appendix 1. One must be photo ID.

Appendix 1: Acceptable identity evidence

Based on the requirements of GPG45, (Good Practice Guide 45 – Identity Proofing and Verification of an individual) the options for presentation of documents are as follows:

2 pieces of Level 3 evidence, or
1 piece of Level 3 evidence and 1 piece of Level 2 evidence

In either case one piece of evidence must include a photograph.

Please see below the list of approved identification evidence:

Level 2 identity evidence:

Birth certificate
Adoption certificate
Marriage certificate
Firearm certificate
DBS Enhanced Disclosure Certificate
HMG issued convention travel document
HMG issued stateless person document
HMG issued certificate travel
HMG issued certificate of identity
Police warrant card
Fire brigade ID card
Building Insurance
Contents insurance
Vehicle Insurance
Mobile telephone contract account
Non-bank savings account
Freedom pass
National 60 +
An education certificate gained from an educational institution regulated or administered by public authority (e.g. GCSE, GCE, A Level, and O Level).
An education certificate gained from a well-recognised higher education institution
Residential property rental or purchase agreement
Unsecured personal loan account (excluding pay day loans)
Proof of age card issued under the Proof of Age Standards Scheme (without a unique reference number)
Unsecured personal loan account (excluding pay day loans)
UK asylum seekers Application Registration Card (ARC)

Level 3 identity evidence:

Mortgage account
Buy to let mortgage account
Current account
Bank credit account (credit card)
Bank Savings Account
Retail bank/credit union/building society
Bank credit account (credit card)
Student loan account
Armed Forces ID card
Digital tachograph card
Northern Ireland Voters Card
US Passports
Passports that comply with ICAO 9303 (Machine Readable Travel Documents)
EEA/EU Government issued identity card comply with Council Regulation (EC) no 2252/2004
Proof of age card issued under the Proof of Age Standards Scheme (containing a unique reference number)
EEA/EU full driving licences that comply with European Directive 2006/126/EC
Secured loan account (including purchase hire purchase)
Non-bank credit account (including credit/store/change cards)

You must now come into the practice with your chosen ID. Proxy access cannot be granted until we have seen both parties ID.

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Adult consent to proxy access to GP online services

Section 1 – Patient Details

Section 2 – Details of access required

Section 3 – Details of the representative(s) seeking proxy access

Identification

Patient ID Required

Representative/Proxy ID Required

Appendix 1: Acceptable identity evidence

Please see below the list of approved identification evidence: