Dissent from secondary use of patient identifiable data

Dear Doctor,

I am writing to give notice that I refuse consent for my identifiable information and the identifiable information of those for whom I am responsible [delete as appropriate] to be transferred from your practice systems for any purpose other than my medical care. 

Please take whatever steps necessary to ensure my / our confidential personal information is not uploaded and record my dissent by whatever means possible. 

This includes adding the ‘Dissent from secondary use of GP patient identifiable data’ code (Read v2: 9Nu0 or CTV3: XaZ89) to my record as well as the ‘Dissent from disclosure of personal confidential data by Health and Social Care Information Centre’ code (Read v2: 9Nu4 or CTV3: XaaVL).

I am aware of the implications of this request, understand that it will not affect the care I / we receive and will notify you should I change my mind.

Yours sincerely,

Signature ____________________________________      Date ________________

Information to help identify my records [please complete in BLOCK CAPITALS]

Title   _______      Surname / Family name   ____________________________________

Forename(s)  	_____________________________________________________________

Address	_____________________________________________________________

		_____________________________________________________________

Postcode 	________________________

Date of birth    ________________________

NHS number (if known)   ___________________________________

Space for additional patient details overleaf

More copies of this letter can be downloaded from www.medconfidential.org/how-to-opt-out

Additional patient details [please complete in BLOCK CAPITALS]

Dear Doctor, please take whatever steps necessary to ensure the following people’s confidential personal information is not uploaded from your practice and record my dissent on their behalf by whatever means possible.

Patient’s full name: ___________________ 

___________________________________

Address: ___________________________

___________________________________

___________________________________

___________________________________

Postcode: __________________________

Date of birth: ________________________

NHS number (if known): _________________

Patient’s full name: ___________________ 

___________________________________

Address: ___________________________

___________________________________

___________________________________

___________________________________

Postcode: __________________________

Date of birth: ________________________

NHS number (if known): _________________

Patient’s full name: ___________________ 

___________________________________

Address: ___________________________

___________________________________

___________________________________

___________________________________

Postcode: __________________________

Date of birth: ________________________

NHS number (if known): _________________

Patient’s full name: ___________________ 

___________________________________

Address: ___________________________

___________________________________

___________________________________

___________________________________

Postcode: __________________________

Date of birth: ________________________

NHS number (if known): _________________

You can provide details of other family members you wish to opt out on a separate sheet, but make sure this letter is attached.

Customisable copies of this letter can be downloaded from www.medconfidential.org/how-to-opt-out