shared_data_opt_out

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GATLEY MEDICAL CENTRE

SHARED CARE DATA OPT OUT FORM

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: ________________

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