Data Sharing Form – Community Health and Social Care Teams

GP practices in England often work with clinicians based in the community to provide better care and support.

For example, District Nurses provide care to housebound patients at the place of their residence, Health Visitors provide care to young children and their families, Community Midwives provide care to pregnant women, Mental Health Teams provide care to patients who require input from specialised clinicians.

Information about you is shared two ways:

GP Practice shares the information with the community teams by allowing them to see the information the Practice holds about you, and;
Community teams share the information with the GP Practice by allowing the Practice to see the information they hold about you. Eleanor Cross Healthcare will share your data with community teams (unless you have opted-out previously).

This is covered by Law. You will be asked for your permission to share information during the initial contact with any of the community teams. Regardless of you previous sharing choice, you do have the option to opt-out, if you do not wish your data shared with these teams, or opt-in at any time.

For more information please see our Privacy Notices.

Data Sharing Form: Community Health and Social Care Team

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Personal Details

Are you completing this form on behalf of: *

Yourself

Someone else (e.g. a child or dependent)

Patient Full Name: *

Your Full Name: *

Your Date of Birth: *

Relationship to Patient: *

Your NHS Number:

Your Telephone Number:

Your Email Address: *

Your Address:

Patient Address: *

Patient Postcode: *

Patient NHS Number:

Sharing Confirmation

Having read the information regarding my choices, I wish to set my sharing preferences as below (please select one option for each):

For sharing information out (this means community teams will be able to access information the practice holds about you): *

I consent (wish to share)

I dissent (do not wish to share)

For sharing information in (this means the practice is able to access information the community teams hold about you): *

I consent (wish to share)

I dissent (do not wish to share)

I understand I can change my preferences at any time by completing another Data Sharing Form.

Signature: *

Date:

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Data Sharing Form – Community Health and Social Care Teams

Personal Details

Sharing Confirmation

New Patients