Summary Care Record and Sharing Consent

Last Updated: 28/05/2021

Your Details

Name *

Date of Birth *

Phone Number *

Email Address

Consent to disclose confidential medical information

We understand that you may have someone close to you involved in your care, due to GDPR guidelines we cannot disclose medical information without your prior consent. This includes; appointment information, results, appointment information ect. If you would like to nominate someone e.g parents, friend or school nurse please complete this section.

Summary Care Record

If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

Please select the content you wish to share. *

a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

b) Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

c) Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below: *

Parent

Legal Guardian

Lasting power of attorney for health and welfare

Not applicable

Please state your name and relation if filling this form out for someone else

Sharing In & Out

Your heath record includes your medical history, details about your medication and any allergies you may have. You can now choose whether to share these full medical details. We use a secure electronic health records system called SystmOne. With your permission, this system can allow clinicians to share your full record held here with other healthcare services who are providing care for you. These other services will ask your permission to view your record. Many organisations may use SystmOne including some GP practices, out of hours services, children’s services, community services and some hospitals. Sharing your health record will help us deliver the best level of care for you. You have two choices which allow you to control how your record is shared. You can change these choices at any time by letting the relevant practice or service know.

SHARING OUT I would like my health record at this practice or service to be shared with other healthcare services providing care for me. *

Yes No

SHARING IN I would like this practice or service to be able to view information in my health record that has been recorded by other healthcare services. *

Yes No

General Practice Data for Planning and Research (Type 1 Opt Out)

Patient data collected from general practice is needed to support a wide variety of research and analysis to help run and improve health and care services. Whilst the data collected in other care settings such as hospitals is valuable in understanding and improving specific services, it is the patient data in general practice that helps us to understand whether the health and care system as a whole is working for patients. NHS Digital will not collect patients’ names or addresses. Any other data that could directly identify patients (such as NHS Number, date of birth, full postcode) is replaced with unique codes which are produced by de-identification software before the data is shared with NHS Digital. This process is called pseudonymisation and means that patients will not be identified directly in the data. NHS Digital will be able to use the software to convert the unique codes back to data that could directly identify patients in certain circumstances, and where there is a valid legal reason. We will collect structured and coded data from patient medical records. You can find out more information here: https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research#additional-information-for-patients-and-the-public

DO YOU WISH TO SHARE YOUR UNIDENTIFIABLE PATIENT RECORD WITH NHS DIGITAL FOR RESEARCH AND PLANNING *

Yes No

Proof of Address & ID

To complete a registration we require proof of address and ID. Please send pictures/scans of the documents you will be providing to CAPCCG.woodlands@nhs.net with your name and date of birth as the subject line.

What form of ID will you be providing? *

Passport

Drivers License

EU Identity Card

Residence Permit

I dont have any of the above (we will contact you via email if you select this option)

What proof of address will you be providing? (less than 6 months old) *

Tenancy Agreement

Utility Bill e.g. gas, electric, water

Council Tax Bill

I dont have any of the above (we will contact you via email if you select this option)

Registration Checklist

All three online forms need to be completed, the surgery may reject your registration if any sections are incomplete.

Have you completed the Pre-Registration Form? *

Yes No

Have you completed the New Patient Questionnaire? *

Yes No

Have you sent your ID & Proof of Address to capccg.woodlands@nhs.net *

Yes No

All online forms need to be completed & supporting documents sent via email, the surgery may reject your registration if any sections are incomplete *

Yes, I understand and have filled in all three forms and sent my supporting documents

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Woodlands Surgery website

Summary Care Record and Sharing Consent

Further Information