Subject Access Request (SAR) Application Form - Personal

Information:

If you are requesting personal data on behalf of someone else, please complete this form instead.

To enable NHS Cheshire and Merseyside ICB to progresses your subject access request for your own personal data held by the ICB, please complete the following information.

Personal data request

We are asking for your identification and contact details, so we can identify you, send our response, and to discuss your request with you if needed.

We will also require proof of identification:

  1. Copy of photographic identification (e.g. passport or driving licence). Please note, any photographic identification must be valid and in date – expired identification is not valid
  2. Copy of a utility bill from the last 6 months showing your name and current postal address. Please note we are unable to accept mobile phone bills as proof of address.

Please send proof of identification with this form when you make your request. Without it, we will not be able to action and progress your request.

Please note that the timescale for responding to your request cannot start until we receive this.

 

Including postcode
You can enter up to 250 characters

Such as a passport or a driving license (supported file types: .pdf, .docx, .png and .jpg)

From the last 6 months showing your name and current postal address (supported file types: .pdf, .docx, .png and .jpg)

Please tell us your preferred communication method

 

Please tell us about the personal data / special category data are you requesting

It is very important that you are as specific as possible about your request.

If it is unclear what you are asking for, or too general, we will contact you, as we will not be able to action and progress your request.

Please note that the timescale for responding to your request cannot start until we receive this.

Is there a date range of the personal data / special category data you’re asking for?

You can enter up to 2000 characters

You can enter up to 2000 characters

 

Final check before sending your request

Please confirm that you have completed all required steps before submitting.

Including: (i) a copy of photographic identification (e.g. passport or driving licence) and (ii) a copy of a utility bill from the last 6 months showing your name and current postal address

Have you provided which ICB Service Area and/or Department, a date range, and anything else to help us with our search?

Without these things, we will not be able to action and progress your request.

Please note that the timescale for responding to your request cannot start until we have everything needed.

 

Declaration and Signature of Applicant

I have completed this Subject Access Request form to the best of my ability.

 

Mersey Internal Audit Agency (MIAA) have been contracted to manage Subject Access Requests for NHS Cheshire and Merseyside ICB. MIAA is an NHS shared service hosted by the Liverpool University Hospitals NHS Foundation Trust. All information provided will be kept private and confidential.

Consent statement

I understand that MIAA have been contracted to undertake the Subject Access Request function on behalf of NHS Cheshire and Merseyside ICB. I understand that in investigating my Subject Access Request that MIAA will need to request from NHS Cheshire and Merseyside ICB any personal data that it holds directly or which is held by organisations contracted by the ICB to undertake key functions, such as IT support.

 

Once you have completed the necessary fields above, press the button below to submit your request.