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.

Details of the Patient

Full Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

NHS Number (if known)

Details of Parent or Legal Guardian

If you are filling 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:

Full Name

Prefix First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to patient

Your Decision

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 and/or I am the parent or legal guardian of the dependent person I am making a choice for set out above (if appliable)

Signature(Required)

Date signed(Required)

Phone

This field is for validation purposes and should be left unchanged.

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Register Your Type 1 Opt-Out Preference