Your decision. Your declaration. When complete, please post or send by email to your GP practice. For GP Practice Use Only

Your decision

Opt-out

I do notallow myidentifiable patient data to be shared outside of the GP practice for purposes except my own care.

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 my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care.

I do allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care.

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 appliable)

Signature

Date signed

When complete, please post or send by email to your GP practice

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For GP Practice Use Only

Date received
Date applied
Tick to select the codes applied	Opt – Out - Dissent code: 9Nu0 (827241000000103 \|Dissent from secondary use of general practitioner patient identifiable data (finding)\|)
	Opt – In - Dissent withdrawal code: 9Nu1 (827261000000102 \|Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)\|)]