Letter template: denial of consent for data sharing

Single signature version

The below template should be copied and sent to every medical provider - GP, optician, dentist, CAMHS, etc. Browse the list of GP and local health board contacts for Wales to find yours. All italicised text is there for guidance and should be deleted once the template has been filled in. If you need the two signature version click here.

Denial of consent for data sharing

Addressee (individual, company or service)

Address

Postcode

Notice of denial of permission for secondary use of patients’ identifiable data

I herewith give notice that I do not consent for my identifiable information, and that of those for whom I am responsible (as detailed below), to be transferred from your practice/service systems for any purpose other than for our medical care. This to take effect from the date at the foot of this notice.

Further, I refuse consent for our identifiable information to be used for any other secondary purposes by those who receive it, other than for our medical care.

I request that all necessary actions are taken to ensure that our confidential personal information is not shared for any other purpose than that stated above.

I further request that this declaration is clearly and prominently recorded on all our medical records by all possible means, no matter which part of the health service, or private medical providers, holds them.

I understand this will not affect the care that we receive.

Please be assured, I will notify you should I change my mind on this matter.

Finally, please provide a copy of your Data Protection Policy, or information about where this can be easily accessed, and a copy of the complaints procedure which applies should any of our data be shared without my specific consent for any purpose other than that specified above.

Signature:                                                                     

Name:                                                                            

Date:                                                                               

Information to assist in identifying my records and those of any person(s) for whom I am responsible, and who are covered by this notice.

[Repeat the following 4 items of personal information for the adult and all children covered by this notice.]

Family name

First name

Date of Birth

NHS number (if known)

The above patients are all registered with your practice/service as living at the following address:

House number/name & street

Locality

Postal Town

Postcode