Type 1 Opt Out Preferences - St Clements Surgery

Please complete our online form

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything. More information about the National Data Opt Out

You can use this form to:

Register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt-out)
withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference ( to Opt-in )

This decision will not affect individual care and you can change your choice at any time, using this form.

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP Practice:

Would you like a Summary Care Record?

Yes

No (Opt-Out)

Name of Patient

First Last

Address

Street Address Address Line 2 City Postcode

Date of Birth

NHS Number Optional

Signature

(Full Name)

Are you filling this form out on behalf of someone else?

Yes

Relationship to Patient

Parent

Legal Guardian

Lasting power of attorney for health and welfare

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.