Data Request Form

Request for access to Personal Data under the General Data Protection Regulation (GDPR) and Data Protection Acts.

Verification Process for Issuing Reports.

Please be advised that prior to the issuance of any data, our governance team will contact you to verify your identity. During this call, you will need to confirm the following details you provided in this form:

Full Name
Email Address
Phone Number

This verification step is mandatory to ensure the security and confidentiality of the information.

Completion of this form is required for the issuance of original histology reports.

REQUEST FOR ACCESS TO RECORDS

Request for access to Personal Data under the General Data Protection Regulation (GDPR) and Data Protection Acts.

Please complete all parts of this form in full.

No fee is chargeable for requests made to access medical files

Are You a VHI patient?(Required)

Yes

Name(Required)

First Last

Contact Phone Number(Required)

Email Address(Required)

Preferred form of access is:(Required)

Please pick one

To receive photocopies

To inspect the original record

Other

Personal Information

If you are requesting personal information in respect of another person, the consent of that person is also required.
A copy of this consent will be required to be send to us prior to any information being issues.

I have signed consent(Required)

Yes

Details of Request

To assist us in locating the data you are requesting, please include as many specific details as possible in relation to your interactions with us in the past. Please tell us the relevant period or timelines involved, particular report or incident.(Required)

The Requester

Name of the Requester(Required)

Title of the Requester(Required)

Date(Required)