Annex A Annex A – Application form for access to Health Records Please Enter the full name of the Data Subject – (person whom medial records are required) * Please confirm who the Data Subject is? * For MyselfFor a third partyFor my childFor a deceased Patient Full Address of patient (or last know address) * Your phone number * Your Email Address * What do you require access for? * Please provide Photo ID – your request may be refused, or you may be asked to supply additional identifying information. Drop a file here or click to upload Choose File Maximum file size: 516MB Any additional notes you would like to share? Submit If you are human, leave this field blank.