Access to Health Records (A2H) request form

Please fill out this form if you are requesting information about someone else.

Is the patient deceased?(Required)
- Yes
- No
To proceed with this request you will need to provide copies of the following documents naming you on the document: 1) A grant of Probate or Letter of Administration. OR 2) A copy of the Death Certificate naming you as the Informant.
Will you be able to provide copies of these documents via email?(Required)
- Yes
- No
As you cannot provide copies of the required documents via email please submit your request via post to:

Individual Rights Team, North West Ambulance Service, Garston Shore Road, Liverpool L24 8RL.

Please do not submit this form, as it will not be received or answered.
To proceed with this request you should be able to provide copies of the following documents:
1. A letter of consent signed by the patient naming you as the information recipient. An acceptable template can be obtained here.
2. Power of Attorney Health and Welfare (Power of Attorney Finances can also be considered).
3. Photo ID of both You and the Patient.
Will you be able to provide copies of these documents via email?(Required)
- Yes
- No
As you cannot provide copies of the required documents via email please submit your request via post to:

Individual Rights Team, North West Ambulance Service, Garston Shore Road, Liverpool L24 8RL.

Please do not submit this form, as it will not be received or answered.
Your full name(Required)
Your email address(Required)
Your home address(Required)
Your contact number
Patient's full name(Required)
Patient's email address
Patient's home address(Required)
Patient's contact number
Date of incident(s)(Required)
Please give accurate date(s) where possible. If you are unsure, then please give date(s) in very close proximity to when 999 or 111 was contacted.
Location of incident(s)(Required)
Please enter as much information about the location to assist in identifying your incident(s). This is especially important if the incident was a road traffic accident.
Nature of incident(s)(Required)
Please detail any information regarding the incident for example, injuries sustained, type of incident (RTC), and hospital conveyed to.
Further information
Please detail any further information regarding your request that you feel may be relevant and may assist in providing the best outcome of your request. Providing as much detail here will avoid any unnecessary delays with your request.
Reason for your request
You are not required to provide a reason. However, it can be helpful in ensuring the correct and relevant information is provided to you. If your request is being made as part of a complaint and/or legal action intended against NWAS, then stating this will ensure the correct team deal with your request.

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Access to Health Records (A2H) request form

Access to Health Records (A2H) request form

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Access to Health Records (A2H) request form

Access to Health Records (A2H) request form

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