Data Rectification Request Form
Personal Information
• Full Name: ______________________________________________________________
• Date of Birth (DD/MM/YYYY): ______________________________________________
• Patient ID (if applicable): __________________________________________________
• Contact Information (Phone/Email): _________________________________________
• Address: ________________________________________________________________
Rectification Details
• Description of Inaccurate Data: [Provide a clear description of the data you believe is
inaccurate.] _____________________________________________________________
• Corrected Data: [Provide the accurate data that should replace the incorrect data.]:
________________________________________________________________________
• Supporting Documentation (if applicable): [Attach any relevant documents that
support your request. This can include identification documents, medical records, or
other relevant materials.]
________________________________________________________________________
Declaration
I hereby declare that the information I have provided in this request form is accurate and true
to the best of my knowledge. I understand that the hospital will take reasonable steps to
verify and rectify the data as per my request and that this process is subject to the hospital's
data protection policies and applicable laws.
Consent
• I consent to the processing of my personal data as provided in this form for the
purpose of rectifying my data records as per my request.
Signature
• Signature:
• Date (DD/MM/YYYY):
Please submit this completed form to the hospital's Data Protection Officer (DPO) or
designated data protection contact. You will receive an acknowledgment of your request and
be informed about the process and timeline for rectification.
For Office Use Only
• Received By: ____________________________________________________________
• Date Received (DD/MM/YYYY): _____________________________________________
• Action Taken:
________________________________________________________________________
• Date of Completion (DD/MM/YYYY): _________________________________________
• Remarks:
________________________________________________________________________
Notes:
• The hospital is committed to ensuring the accuracy and integrity of patient data and
will respond to this request in accordance with GDPR requirements and healthcare
data protection policies.
• If further information or clarification is needed, you may be contacted.
• The rectification process timeline will depend on the complexity of the request and
the verification process required.
