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: 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 prefer you can download an easy-read version of this information: assets.nhs.uk/patient-information

Are you completing this form on behalf of: *

Yourself

Someone else

Patient First Name(s): *

Patient Surname: *

Your Full Name: *

Relationship to Patient: *

Phone Number: *

Email Address: *

Address:

Postcode:

NHS Number:

Your Decision

Please select one of the following: *

Opt Out: 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.

Withdraw Opt-Out (Opt-In): 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

Your Declaration

I confirm that: *

The information I have given in this form is correct

Please select one of the following: *

I am completing this form for myself

I am the parent or legal guardian of the dependent person I am making a choice for

Signature: *

Date:

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Register your Type 1 Opt-Out Preference