Consent to Proxy Access to GP Online Services (Adult)

Section 1 – Patient Details

(This is the person whose records are being accessed)

All responses we send will go to this email address.
Please confirm the folllowing:

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.

Section 2 – Details of access required

Please tick proxy access required:

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)

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:

Representative 1
Representative 2

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 tick the documents you are submitting:

Level 2 identity evidence:
Level 3 identity evidence:

Maximum file size: 67.11MB