Summary Care Record opt out form - Leeds Student Medical Practice

Your Summary Care Record shares only your contact details, medications and allergies with other
healthcare professionals involved in your care.

You can also choose to share a Summary Care Record with Additional Information. This shares contact details, medications, allergies, diagnosis list, care plans, end of life care and immunisations with other healthcare professionals. Sensitive data is excluded. A Summary Care Record with Additional Information will only be created for you if you explicitly choose this option. Only the most up to date information is shared for each category (EMISWeb). All current and past information is shared for each category (SystmOne).

Your Summary Care Record is an opt out system, it is shared as standard. Choosing to share a summary care record with additional information is thought to be of great benefit if you are admitted to hospital locally or elsewhere in the UK.

You can opt out of sharing any of your information in a Summary Care Record. If you decide not to share this will not affect your entitlement to care. However, it could result in the delivery of your care being less efficient as other health professionals will not have access to these parts of your medical history.

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP Practice:

Would you like a Summary Care Record?

Yes

No (Opt-Out)

I would like my Summary Care Record to…

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Name of Patient

First Last

Address

Street Address Address Line 2 City Postcode

Date of Birth

NHS Number Optional

Signature

(Full Name)

Are you filling this form out on behalf of someone else?

Yes

Your Name

First Last

Relationship to Patient

Parent

Legal Guardian

Lasting power of attorney for health and welfare

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.