Victoria Road Surgery Data sharing Out” form. “Opt I confirm that I know enough the various data extractions in place or proposed. Please block data extraction from the patient whose details appear below. I specify the precise areas I wish to block below: Title of patient Surname of patient Forename of patient Address Phone No. (Mobile if possible) Date of Birth. Patient’s Signature (unless a child aged under 18) Date If completing this on behalf of a child, please also complete below: Your name (BLOCK CAPITALS) Your signature: Your relationship to the patient Please tick any or all of the 4 areas detailed below that you wish to prohibit data extraction to: Area involved Tick those from which Practice use you wish to prohibit use only of your data 1. Summary Care Record (SCR) 9Ndo 2. Any local (e.g. CCG) Care Record 93C1/9Ndj 3. National scheme 9Nu0 “Care.Data” (including Section 251) 4. Use of your data from other 9Nu4 sources: (AandE, Hospitals etc) PLEASE RETURN THIS FORM TO PRACTICE RECEPTION: Or Email it to the following practice address: CWSCCG.victoriaroad-worthing@nhs.net
Victoria Road Surgery Data sharing “Opt Out” form. I confirm that I know enough the various data extractions in place or proposed. Please block data extraction from the patient whose details appear below. I specify the precise areas I wish to block below: Title of patient Surname of patient Forename of patient Address Phone No. (Mobile if possible) Date of Birth. Patient’s Signature (unless a child aged under 18) Date If completing this on behalf of a child, please also complete below: Your name (BLOCK CAPITALS) Your signature: Your relationship to the patient Please tick any or all of the 4 areas detailed below that you wish to prohibit data extraction to: Area involved Tick those from which you wish to prohibit use of your data Practice use only 1. Summary Care Record (SCR) 9Ndo 2. Any local (e.g. CCG) Care Record 93C1/9Ndj 3. National “Care.Data” scheme (including Section 251) 9Nu0 4. Use of your data from other sources: (AandE, Hospitals etc) 9Nu4 PLEASE RETURN THIS FORM TO PRACTICE RECEPTION: Or Email it to the following practice address: CWSCCG.victoriaroad-worthing@nhs.net