Aspen Centre, Horton Road, Gloucester, GL1 3PX, Tel: 01452 337733
Tuffley Surgery, 38 Warwick Avenue, Tuffley, Gloucester, GL4 0SL. Tel:01452 22959
NHS ENGLANDS CARE DATA – OPT OUT FORM
Title:______ Surname/Family Name________________________
Forename________________ Date of Birth__________________
Address_______________________________________________
Signature____________________ Date______________________
If you are filling out this form on behalf of a child under the age of 16, please ensure that you fill out
a separate form including their details (above).
Signature on behalf of a child under 16___________________
Relationship to that child______________________________
NHS England’s care data system aims to provide timely, accurate information to citizens, clinicians
and commissioners about the treatment and care provided by the NHS. Please refer to the NHS
Englands ‘Better information means better care’ leaflet before completing this form. You can also
find more information by visiting www.nhs.uk/caredata, or by calling the NHS dedicated patient
information line on 0300 456 3531
Opt out form – Confidential
A. Please tick this box if you do not want your GP to release any of your GP record to the Health
and Social Care Information Centre for purposes of the care data system.
B. Please tick box if you do not want the Health and Social Care Information Centre to disclose
to any accredited third parties any information they hold on you (from any NHS source).
Please note that in general, such data would only be made available to accredited third
parties in anonymised, pseudonymised or aggregated form.
SUMMARY CARE RECORD Opt out
The Summary Care Record (SCR) provides a summary of patients’ medical records to all authorised
healthcare staff treating them, anywhere in the NHS in England.
Patients can choose to opt out of the programme (i.e. express dissent). If patients do not actively
express dissent, implied SCR consent is assumed, and their SCR information is uploaded to the Spine.
C.
Please tick box if you do not want a summary care record.
Staff only
Opt out codes for HSCIC (Care Data):
’Dissent from secondary use of GP patient identifiable data’ code: 9Nu0
Dissent from disclosure of personal confidentialdata by Health and Social Care Information Centre’ code:
9Nu4
Opt out codes for Summary Care Record: Code to be added to records: Express Dissent for Summary Care Record dataset
upload .9Ndo or use the Sharing Consent button for SCR – this is located on the registration page.