Care Data Opt-Out

If you would like more information about the care.data programme and/or you need some assistance with making your decision please contact the national patient data sharing helpline on 0300 456 3531

Care Data: Opt-Out Form

If you are human, leave this field blank.

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: *

NHS Number (if known):

Home Address

Postcode

Preferred Phone Number *

Electronic Signature: *

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:

Relationship to Patient

Your Electronic Signature:

Date

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Care Data: Opt-Out Form

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

Section B

Hay Fever