Consent to proxy access to GP online services

Use this form to give permission to the GP practice for representatives to have proxy access to certain online services.

If you are human, leave this field blank.

Does the patient have the capacity to consent to grant proxy access? *

Yes

Consent

I, the patient, give permission to my GP practice to give the following person/s proxy access to the online services as indicated below.

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 understand the information leaflet provided by the practice.

Signature: *

Enter full name of patient

Date:

The Representative/s

These are the people seeking proxy access to the patient’s online records, appointments or repeat prescriptions.

Access to be granted:

Online appointments booking

Online prescription management

Limited access to parts of the medical record for the patient

Please select all that apply

I/we, the representative/s wish to have online access to the services selected above for the patient.

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

Confirmation: *

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 see or download

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 is 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

Full Name of representative 1: *

Date of Birth of representative 1: *

Relationship to patient of representative 1: *

Address of representative 1: *

Please include postcode

Email Address of representative 1: *

Telephone Number of representative 1: *

Mobile Number of representative 1:

Signature of representative 1: *

Please enter full name

Date:

Full Name of representative 2:

Date of Birth of representative 2:

Relationship to patient of representative 2:

Address of representative 2:

Please include postcode

Email Address of representative 2:

Telephone Number of representative 2:

Mobile Number of representative 2:

Signature of representative 2:

Please enter full name

Date:

ID Upload

Please upload photo ID for the representative/s seeking access:

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Consent to proxy access to GP online services

Consent

The Representative/s

ID Upload

Care Quality Commission