Proxy Online Access Application Form 

(For patients who are receiving care and / or for children aged 15 years or younger)

 

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Please read carefully the following information carefully (both the patient and the person who is requesting proxy access)

  • The following form is to add a “proxy” user to your existing Online Access Account with either NHS app or Patient Access
    • … OR to register a proxy user to manage a new account on your behalf.
  • The named proxy user on this form will have access to your medical record and will be able to order repeat medication and book appointments on your behalf. Your proxy does not have to be a patient of this practice* (Note: this is not available on the NHS app currently July 2021. So please use Patient Access if you are not registered at Amersham Vale Practice)
  • Proxy is a new service; procedures and terms for registering may change without prior notification.

Please read the full terms and conditions below of this form.

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Patient’s Details (Patient who is receiving care, or the child under 15 years)

To give consent for proxy access to their online services

Consent

To be completed by the person named above unless lacks capacity because of medical condition, or a child under 11 years.

I give consent for the person named below to have online services access to: 

Patient Lacks Capacity

Please provide copy of legal paperwork (Power of Attorney/Court Appointed Deputy). If paperwork cannot be supplied then GP will need to confirm incapacity before access is given. 

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Please note we will need to see the original copy of this form before we can give access. Please upload a copy here. We will contact you to arrange a suitable date to come in with the original paperwork. Failure to upload/provide proof means access will not be granted.

Patients aged 16 or over only
ID Proof Required

Please provide a proof of ID* We may need to see the originals, we will contact you if this is needed.

Acceptable forms of ID:

Passport (in date)
Drivers Licence (Full or provisional with photo)
Birth Certificate

We will contact you to arrange a time to see your ID proof in person, if applicable
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
The chosen person to have proxy access for the named person above

We need these details to be able to trace your existing online user account

(if registered at another practice)

If you are registered with us, access will be added to your existing Online Services account – you will be able to switch to child/cared for person’s account via Linked Users (in drop-down menu under your name). If you are registered elsewhere, we will email you the registration document you need in order to link your account to our practice patient, so please make sure your email is correct above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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PROXY ACCESS TERMS AND CONDITIONS

1. When an “age maturity” patient (with a proxy) reaches the age of 11 the account will be become restricted (access to book one appointment only).

  • The proxy user will be notified automatically by email 3 months before the patient’s birthday.
  • A clinician will upon request assess whether or not the patient is competent to manage their own account.
  • If deemed competent the proxy account will be disabled and the child will be required to register as a full user of Patient Access (or NHS app access) by completing an Online Patient Access Application form.
  • If deemed not competent the proxy account will remain until the child turns 16.
  • Emails sent automatically when a child attains the age of 11 are sent from Patient Access and not from Amersham Vale Practice.

2. When an “age maturity” patient (with a proxy) reaches the age of 16 the account will be closed.

  • Patients aged 16 and over are deemed competent to manage their own healthcare.
  • The proxy user will be notified automatically by email 3 months before the patient’s birthday.
  • The child will be required to register as a full user of Patient Access by completing an Online Patient Access Application form.
  • In some circumstances it may be necessary for the proxy to continue to manage the affairs of a child who has turned 16.
  • Emails sent automatically when a child attains the age of 16 are sent from Patient Access and not from Amersham Vale Practice.

3. All requests from the proxy user to continue to manage the affairs of a child will be assessed by a clinician. There may be a wait of up to two weeks for the request to be accepted or rejected. The proxy user will be notified by the practice when the request has been approved or if it has been rejected.

4. Proxy access for adult patients remains indefinitely until either the patient informs us they no longer wish the proxy user to have access (and their link will then be removed); or the proxy user informs us they no longer wish to have control of the patient’s account – and their link will then be removed. The practice will inform both parties when links have been removed.

5. If a child’s medical record contains a Gillick or Fraser competency code the patient is deemed competent to manage their own account and requests for proxy access will be rejected. The proxy user will be notified by the practice. If a competency code is added at any time while the patient has a proxy user the link will be removed and the proxy user will be notified by the practice. For more information about Gillick/Fraser competency please visit: https://www.nhs.uk/conditions/consent-to-treatment/children/

6. Failure to comply with these terms and conditions and the stipulations on the form will mean a revocation of the proxy user’s link to the patient’s account.

7. Abuse of the system in any way will mean a revocation of the patient’s account (if they have one) and the proxy user. New requests for a Patient Access (or NHS app access) or Proxy account from either party will be rejected. The practice does not have to give a reason for rejecting a request.

8. We recommend the proxy uses Patient Access (or NHS app) to manage the affairs of the patient or their own medical record. Other online services are available however Amersham Vale Practice does not support these, if you require technical support you’ll need to contact those service providers directly.

9. If you do not have Care Record Viewing enabled on your account (or you do not currently have a Patient Access account or NHS app Access) but you want your Proxy to have access to your detailed medical record, there will be a delay while your application is authorised.

10. Amersham Vale Practice will endeavour to help with any technical issues you may be having with Patient Access (or NHS app access), however we recommend contacting Patient Access support via Patient Access Support Portal at first and foremost as they are more equipped to help with issues related to their service or for the NHS app Contact the NHS App team (www.nhs.uk)

11. The service is provided solely for the use of the registered patient and/or proxy user i.e. the patient or their parent/guardian, carer or power of attorney named on the application form.

12. Passwords/logon credentials should be kept secret. Do not pass on the details of passwords to anyone else.

13. The practice cannot guarantee that the Patient Access service or other service providers will be continuously available.

14. If you have a complaint or want to leave feedback about the Patient Access service (or NHS app access) or Proxy Access please direct your complaints or feedback to Contact Support for Patient Access or for the NHS app via Contact the NHS App team (www.nhs.uk). We regret that Amersham Vale Practice cannot accept complaints or feedback about Patient Access (or NHS app access) as the systems are run and maintained by a third party.

15. If you suspect that your account has been accessed by someone without your agreement you will contact the practice as soon as possible.

16. If you see information on your record that is not about you or is inaccurate, you will contact the practice as soon as possible.

17. We may update these terms and conditions at any time. The latest version of this form, including the terms and conditions, will always be available on our website at www.amershamvale.co.uk and from reception. By signing the Proxy Online Access form you agree to the terms and conditions as outlined on the latest version of the form.

19. Failure to comply with any of the above conditions may result in revocation of access to the service.

Proxy Access Application Form v1.0 (July 2021)