Opt Out of Online Services Request Form

SHIRLAND MEDICAL OPT OUT OF ONLINE SERVICES REQUEST FORM

From the 1st of November 2023 patients who are registered with SystmOnline or any other NHS App will be able to request full prospective online access. This includes their consultation information, test results and documents e.g. hospital letters. You will still be able to book appointments,

Not all patients wish to see their full medical record information online. All patients have the right to opt out of this. Please complete the form below if you wish to OPT OUT of viewing your full medical record online.

You may prefer not to have prospective access in case of the following:

Harm from exposure through premature access to upsetting investigation results or documents without adequate preparation or an opportunity for the GP or hospital doctor to review these with you in a supportive environment.
Risks to those that may be under pressure to release their records to another person or organisation. e.g. a controlling partner or family member. (Coercive Control Risk).
If you are concerned about NHS records security and ability of others to fraudulently access this.
Risk of unintended misinterpretation of information through medical jargon and acronyms.
Disclosure of harmful third party information.

Opt Out of Prospective Access Form

Name

First Last

Date of Birth

Essential to access online services

Home Telephone Number

Mobile Telephone Number

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Any comments you wish to make or reason for opt-out:

I wish to opt out of viewing my full medical record online. I wish to retain the ability to (please tick all that apply):

Book Appointments

Yes

Request Repeat Medications

Yes

See Coded Information

Yes