I WISH TO OPT OUT OF SHARING MY DATA IN ACCORDANCE WITH THE 2012
HEALTH AND SOCIAL CARE ACT. I AM AWARE THAT THIS WILL PREVENT MY
CONFIDENTIAL INFORMATION BEING USED OTHER THAN WHERE NECESSARY BY
LAW (for example, if there was a public health emergency)
I FURTHER UNDERSTAND THAT THERE ARE 2 ELEMENTS TO THIS OPT OUT AND
HAVE TICKED THE APPROPRIATE BOXES IN ACCORDANCE WITH MY WISHES.
OPT OUT 1:
I am happy for my data to be shared with the Health and
Social Care Information Centre (HSCIC) but not for it to be shared with anybody or organisation outside of the HSCIC.
OPT OUT 2:
I do NOT want my data to be shared with the HSCIC
NAME : _____________________________________
ADDRESS: _________________________________________________________
_________________________________________________________
Date of Birth: ___ / ____ / ______
Signature: _______________
For staff purposes only:
(circle as appropriate)
Opt Out 1: Ticked: Y / N Coded: Y / N Scanned: Y / N
Opt Out 2: Ticked: Y / N Coded: Y / N Scanned: Y / N
Coded by: ___________ Scanned by: ________________