Register your TYPE 1 Opt-out Preference

The Avenue Medical Centre: Patient Type 1 Opt-Out Preference Form

Last Updated: 11/06/2021

Type 1 Data Opt-out Form

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. This form, once completed, should be sent to your GP practice by email or post.

Patient Details

Title *

Forename (s) *

Surname *

Address *

Main Phone Number

Date of Birth *

NHS Number (If Known)

Details of parent or legal guardian

If you are filling in 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:

Name

Address

Relationship to patient

Register your Type 1 Opt-out preference

Opt-out: I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care.

Yes No

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.

Yes No

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.

Yes No

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.

Yes No

Your Declaration

I confirm that:  the information I have given in this form is correct.  I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable)

Your Name *

Date *

For GP Practice Use

Opt-out dissent Code: SNOMED (827241000000103) Opt- In dissent withdrawal Code: (827261000000102)

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Register your TYPE 1 Opt-out Preference

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