[Enter name and address of employee]
[Enter date]
Private and confidential
Dear [insert name of employee],
Consent to medical [examination and] report from your doctor
We write to, request your consent to obtain a written medical report from your doctor (including any required examination). We require this to assess your fitness for and likely return to work, what assistance we may be able to offer you to assist your return to work, either on a temporary or permanent basis, to assess your continued eligibility for sick pay and to understand the effect of your condition on your day-to-day activities.
Having obtained the report, we will meet to discuss the report and next steps. If you do not provide consent, we will have to reach a decision without the benefit of medical advice based solely on the information available to us.
[Your contract of employment (clause [insert number]) states that you agree to the Company obtaining a medical report and [to you undergoing a medical examination]. Refusing consent would therefore be a breach of contract and could result in disciplinary action.]
Since producing the report will involve processing personal sensitive and medical data, your consent will be required according to the Data Protection Act 1998 as well as the Access to Medical Reports Act 1988 (we attach a statement of your rights under this Act). You may ask to see the medical report before it is provided to us.
Please complete and return the enclosed consent form. We will then contact your doctor to obtain the report.
If you have any questions about this process please contact [insert name].
Yours sincerely,
[insert name of employer’s representative]
Encls: consent form
AMRA rights statement
Date:
[insert date]
Employee name:
[insert name]
Employee date of birth
[insert date of birth]
Employee address:
[insert address]
Employer name:
[insert name]
Private and confidential
To: [insert name of doctor]
I confirm that:
• I am a patient of yours
• I understand that my employer wishes to obtain a medical report from you in order to obtain an up-to-date, accurate and expert assessment of:
• my fitness to resume work as [insert job title]
• when I am likely to be able to wholly or partly resume my duties
• the effect of my condition on my day-to-day activities
• the range of reasonable adjustments my employer may need to make
• my eligibility for sick pay
• other: _______________________
• I [do not]* consent to you producing a [written/oral]* report for my employer on my medical condition
• I [do not]* agree to undergo examination by you to enable you produce such a report with the benefit of up-to-date information on my medical condition
• I [do not]* agree to you discussing your findings with my employer after producing your report
• I [do not]* consent to the processing [by you/my employer]* of my sensitive personal data required in order to carry out the above
• I have read and understood a summary of my rights under the Access to Medical Reports Act 1988
• I [do not]* wish to see a copy of the medical report before it is supplied to my employer
• I am willing to pay your reasonable fee for sending me a copy of the report/I will contact you within 21 days of my employer’s request to make an appointment to view the report*
* employee to delete as applicable
Signed:_____________________
Name of employee: Date:
As an employee, you have certain rights under the Access to Medical Reports Act 1988:
• You are entitled to have access to any medical report obtained about you for employment or insurance purposes
• You are entitled to be notified that we propose to apply for a medical report concerning you and that we require your consent to do so
• You are entitled to withhold or give your consent to that proposal
• Where you give your consent, you are entitled to state that you wish to have access to the report before it is sent to us
• You are entitled to change your mind about withholding or giving consent
• You are entitled to change your mind about having or not having access to the report before it is sent to us (as long as you tell us you have changed your mind before the report is actually sent to us), subject to the timescales identified below
• Where you request access to the report before it is sent to us, you are entitled to have the doctor notified of this requirement by us and for us to let you know when we have made the application for the report
• Where you do request access to the report, this means it will either be made available for you to inspect or you will be sent a copy (for which the doctor may charge a reasonable fee to cover his/her costs). Even if you initially decide not to request access to the report before it is sent to us, you can still ask the doctor for access to it up to six months after he/she has sent it to us
• Where you do require access to the report before it is sent to us, you must contact the doctor within 21 days of when we apply for the medical report to arrange to see it, otherwise if the doctor hasn’t heard from you within 21 days, the doctor can send it to us without having to contact you or give you access to it first
• If you change your mind because you now want to see the report you should contact your doctor and make arrangements to see the report within 21 days of contacting your doctor; if your doctor does not then hear from you within 21 days about those arrangements, your doctor can send it to us without having to contact you or give you access to it first
• Where you have asked to see the report before it is sent to us, it will only be supplied to us if you tell your doctor that you agree to it being sent to us. You do not have to give that consent
• Where you are given access to the report, and you think that all or part of it is incorrect or misleading, you can ask to the doctor in writing for the report to be amended before it is supplied to us (although he/she is not obliged to do so)
• Where you ask for the report to be amended but the doctor does not do so, you can either agree to the report being sent to us unaltered; or ask the doctor to attach a statement setting out your views to the report; or withdraw your consent for the report to be supplied
• The doctor does not have to give you access to any part of the report that he/she considers:
◦ might cause serious harm to your physical or mental health, or that of others, or
◦ might indicate his/her intentions towards you, or
◦ would reveal information about a third party or the identity of a third party who has given the doctor information about your health, unless that person consents or is a health professional involved in your clinical care
• Where the doctor chooses not to give you access to part of the report in any of these circumstances, he/she will notify you of this in writing and will allow you to see the remaining parts
• Where the doctor considers that the circumstances apply to the whole report, he/she will not give you access to it but will not send it to us either, unless you consent to him doing so