Wallington Family Practice > Services > Forms > Keep us up to Date > Type 1 Opt Out

Type 1 Opt Out

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

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 ( to Opt-in )

This decision will not affect individual care and you can change your choice at any time, using this form.

Details of person completing the form

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Are you completing this on behalf of a dependant?

Yes

e.g. a child. Please note the Practice will first confirm that you have the authority to do so

Dependant’s First Name

Dependant’s Last Name

Dependant’s Address

Your relationship to your dependant

NHS Number

If known

Preferences for patient & declaration of person completing form

Preference for Patient

OPT OUT – 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 the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care.

Parent or legal guardian declaration

I am the parent or legal guardian of the dependent person I am making a choice for set out above

Signature: I confirm that the information I have given in this form is correct

Clear

Sign or type to indicate your signature

Preferences & Declaration

Preference your Patient data

OPT OUT – I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my 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.

Signature: I confirm that the information I have given in this form is correct

Clear

Sign or type to indicate your signature

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

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