Summary Care Record Opt-Out Form
Request for my clinical information to be withheld from the Summary Care Record
If you DO NOT want a Summary Care Record, please complete this form. If you are completing this form on behalf of another person, please ensure you provide both their details and your details below.
Details of Person Completing This Form (if not the Patient)
Further Information
What does it mean if I DO NOT have a summary health care record?
NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.
Your records will stay as they are now with information being shared by letter, email, fax or phone.
If you have any questions, or if you want to discuss your choices, please phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.
Privacy Protection
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.