Better Information Means Better Care – Sharing of Personal Confidential
Information
Coastal Medical Group Opt Out Form
I have read the ‘Better Information Means Better Care’ Leaflet and wish to prevent
my personal confidential data from:
1. Leaving the GP Practice and being sent to the Health & Social Care
Information Centre’s Secure Environment
Y/N
2. Leaving the Health & Social Care Information Centre’s Secure
Environment
Y/N
Please return this form to Coastal Medical Group
To be completed by the individual (data subject) making the request.
Please complete in BLOCK CAPITALS.
--------------------------------------------------------------------------------------------------------Title:
Surname/Family Name:
Forenames:
Address:
Postcode:
Telephone No:
Date of Birth:
NHS No (if known):
Signed:
Date:
Office Use Only:
Hand this form to IT to action. IT to sign when completed:
Signed:
Date:
Pass to scanning when completed.