Care Data Opt Out Form

Please tick one or both options below: *

I do not want my personal confidential data to be released by my GP surgery for the care.data programme

I do not want my personal confidential data from hospitals and other care providers to be released by the Health & Social Care Information Centre (HSCIC) for the care.data programme

Section A: it is important that you complete this section accurately

Full Name: *

Date of Birth: *

NHS Number (if known):

Home Address

*

I confirm that the information provided is accurate to the best of my knowledge.

Postcode

Preferred Phone Number *

Email address *

Any responses we send will go to this email address.

Date

If you are filling out this form on behalf of another person or child, their GP practice will check that you have the authority to do so. Please ensure you fill out their details in Section A and your details in Section B.

Section B

Your Name:

Date

Relationship to Patient

*

I confirm that the information provided is accurate to the best of my knowledge.

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