Nightingale NHS data-sharing type-1 opt-out June 2021

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. You can use the form below to tell us your preferences.

Last Updated: 05/07/2021

Patient Details

Title *

Forenames *

Surname *

Address *

Mobile and landline telephone numbers

Date of Birth *

NHS Number (if known)

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:

Dependent's name

Address

Relationship to person filling in the form

Register your Type 1 Opt-out preference

You decision

I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care. OR I do not allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes except their own care.

Opt out

I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care. OR I do allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care.

Withdraw Opt-out (Opt-in)

Your Declaration

I confirm that: • the information I have given in this form is correct • I am the parent or legal guardian of the dependent person I am making a choice for set out above (if appliable)

Your full legal name *

Date completed *

For GP Practice Use only

Date received

Date processed

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Opt-In – Dissent withdrawal code: 9Nu1 (827261000000102 |Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)|)]

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Nightingale NHS data-sharing type-1 opt-out June 2021

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