Cranleigh Gardens Medical Centre
Bridgwater

OPT-OUT FORM

Dissent from secondary use of patient identifiable data

If you DO NOT want your data to be shared please fill out the form and send it to your GP practice

A. Please complete in BLOCK CAPITALS 

Title .................................................................  Surname / Family name  .............................................................

Forename(s)  .........................................................................................................................................................

Address  .................................................................................................................................................................

Postcode  ....................................................................... Phone No  .....................................................................

Date of birth  .....................................................  NHS Number (if known)  ...........................................................
.

I confirm I have read the practice leaflet “How Information in your Medical Records is used to improve health care” and DO NOT wish for my identifiable personal and confidential data to be extracted by the Health and Social Care Information Centre on behalf of NHS England.  I understand that I may reverse this refusal in future, should I change my mind.

Your signature ………………………………………………Date………………………………………………………

B. If you are filling out this form on behalf of another person or a child, their GP practice will consider this request. 

Please ensure you fill out their details in section A and your details in section B

Your name..................................................................      Your signature......................................................

Relationship to patient .....................................                Date .....................................................................

Actioned by practice: (Add code 9Nu0 and 9Nu4 to record)  YES/NO   Date ....................................................