KINGSBRIDGE MEDICAL PRACTICE

HEALTH AND SOCIAL CARE INFORMATION CENTRE 

OPT- OUT FORM

Request for my clinical information to be withheld from the Health and Social Care Information Centre (HSCIC)

If you do not want your clinical information to be passed to the HSCIC please complete the details below and pass it to a member of the Practice team.

Section A

Please complete following details:

Title:………………….	Family Name…………………………………..

First Names:……………………………………………………………………

Address:………………………………………………………………………….

……………………………………………………………………………………

……………………………………………………………………………………

Signature:……………………………………………………………………….

If you are completing this on behalf of a child please fill their details in section A and your details in section B

Section B

Your name:……………………………………………………

Relationship to patient:………………………………………

Your signature:……………………………………………….

Date:……………………………………………………………

For Practice Use

Actioned by:				Date:			Read codes input: