Sharing your health records Opt-Out form Confidential Request for my clinical information to be withheld from the NHS Care.data programme Any patient who subsequently wishes to opt out of this project can have the read codes listed below added to their GP record to ensure that their records are not included in any data extraction. Please complete in BLOCK CAPITALS Title Surname / Family name ………………… ………………………………….………………………………………… Forename(s) ………………………………………………………………………………….……………………………………….. Address ………………………………………………………………………………………….……………………………………….. Postcode Phone No Date of Birth …………..………… ………….…………………… ………………………………. NHS Number (if Signature ……………………….... …………….…………………………………………… If you are filling out this form on behalf of another person or a child, their GP Practice will consider this request. Your name……………………….…………………… Your signature ………..……….…………………………………….. Your relationship to Patient ………………………............ Date …………………………………………………… Dissent from Secondary use of general practitioner patient 9Nu0 (READ2), XaZ89 (CTV3) identifiable data Declined Consent for use of patient data in Risk 9q7 (READ2), XabjB (CTV3) Stratification
Sharing your health records Opt-Out form Confidential Request for my clinical information to be withheld from the NHS Care.data programme Any patient who subsequently wishes to opt out of this project can have the read codes listed below added to their GP record to ensure that their records are not included in any data extraction. Please complete in BLOCK CAPITALS Title ………………… Surname / Family name ………………………………….………………………………………… Forename(s) ………………………………………………………………………………….……………………………………….. Address ………………………………………………………………………………………….……………………………………….. Postcode …………..………… Phone No ………….…………………… Date of Birth ………………………………. NHS Number (if ……………………….... Signature …………….…………………………………………… If you are filling out this form on behalf of another person or a child, their GP Practice will consider this request. Your name……………………….…………………… Your signature ………..……….…………………………………….. Your relationship to Patient ………………………............ Date …………………………………………………… Dissent from Secondary use of general practitioner patient identifiable data 9Nu0 (READ2), XaZ89 (CTV3) Declined Consent for use of patient data in Risk Stratification 9q7 (READ2), XabjB (CTV3)
Sharing%20your%20health%20records%20Opt%20Out%20form.docx