Subject Data Access Form - Advinia Health Care - Residential and Nursing Care Homes in the United Kingdom

Fields marked • are required.

The maximum uploaded file size is: 512Mb

Section 1 - About yourself

Title • First Name(s) • Surname / Family Name • Date of Birth Sex Maiden / Former names • Telephone number (day) • Email address • Home address • Postcode Name of Care Home (if applicable) Address of Care Home If you would have been known to us by a different name, or at a different address (home or business) during the period to which the information you are seeking relates, please state the name(s) and address(es) below: Name 1 From (date) To (date) Name 2 From (date) To (date) Address 1 Postcode From (date) To (date) Address 2 Postcode From (date) To (date)

Section 2 - Proof of identity

To help establish your identity, you must submit a copy of one document from each of the following categories with your application: (a) Confirmation of name - full driving license*, passport, birth certificate (b) Confirmation of name and address: - full driving licence*, utility bill, bank or credit card statement, child benefit book, pension book (or other equivalent/similar official document – but it MUST show your name and address). *Complete copy of both parts of your full (not provisional) driving license will be sufficient for both categories. *Please note if you are making a request on behalf of a Resident you will need a letter of authorisation from them or a Power of Attorney. I am providing the followint to act on behalf of the above name Resident (a) (b) • Identification for category (a) • Identification for category (b)

Section 3 - Helping us find the information

Please use the space below to provide further details that may help to locate the information sought. For example, specific documents or information that you are seeking; the likely location of the information; the name of the person in Advinia who may have created or had access to the information; and any relevant time periods. If you are seeking to obtain an electronic copy or to have your data deleted here, please also include the relevant information below. Additional Information

Section 4 - Declaration

By submitting this form, you are confirming that the information provided is correct to the best of your knowledge and that you are the legally owner of the aforementioned personal data requested.

Warning – attempting to obtain personal data to which you are not entitled may be an offence under the Data Protection Act.