Register your Type 1 Opt-out Preference

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 is here: https://www.nhs.uk/your-nhs-data-matters/

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 (Opt-in)

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

If you are completing this form for yourself and your dependants, you must complete one form per person.

Details of the Patient

Title

If other, please specify

Forename

Surname

Address

Telephone Number

Date of Birth

Details of Parent or Legal Guardian

If you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below:

Name

Address

Relationship to Patient

Your Decision

Your Declaration

I confirm that:

the information I have given on this form is correct.

I am the parent or legal guardian of the dependent person I am making the choice for set out above (if applicable)

Please type your full name below to confirm the details provided on this form are correct:

Date signed

FOR OFFICIAL USE ONLY - To be completed by GP Surgery

Date Received ___/___/_____

Date applied ___/___/_____

[_] - Opt – Out - Dissent code: 9Nu0 (827241000000103 |Dissent from secondary use of general practitioner patient identifiable data (finding)|)

[_] - Opt – In - Dissent withdrawal code: 9Nu1 (827261000000102 |Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)|)]

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Dr G. Sani & Partners • City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry, CV1 4FS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.