Adult Consent Form

Consent to Share Confidential Information (inc. Online) with a Third Party Reepham & Aylsham Medical Practice – Patient Information Leaflet

Practices are increasingly enabling patients to be able
to request repeat prescriptions and book appointments
online.


Some patients may wish to access more information
online and from 1st April 2017 patients are now able to
view medical record ‘free text’ entries and
communications which have been added to your record
since that date. However, in requesting this access we
ask you make additional considerations as outlined in
this leaflet.

Sharing your Information with a 3rd party
It is up to you whether you share your information with
others – perhaps family members or carers. It is your
choice but also your responsibility to keep the
information safe and secure.

Access can be granted to a primary carer e.g., parent of
a child’s medical records up until 12yrs of age. After
this and as per data protection laws it is appropriate to
consider the consent (if competent) of the child to give
access or dissent to refuse access of their records to
others and therefore at this point a review of access
will need to take place.


It is your responsibility to inform us if you wish to
change permissions previously granted to any 3rd party
and important that the considerations given here are
made before filling in the consent form below.

Forgotten History
There may be something you have forgotten
about in your record that you might find
upsetting


Abnormal Results or Bad News
If your GP has given you access to test results
of letters, you may see something that you
find upsetting to you. This may occur before
you have spoken to your doctor or while the
surgery is closed and you are unable to
contact them.

Coercion
If you think you may be being pressured into
revealing details from your patient record to
someone else against your will, it is best that
you do not register for access at this time


Misunderstood Information
Your medical record is designed to be used by
clinical professionals to ensure that you
receive the best possible care. Some of the
information within your medical record may
be highly technical, written by specialists and
not easily understood. Please contact the
surgery for a clearer explanation


Information about someone else
If you spot something in your record that is
not about you or notice any other errors,
please log out of the system immediately and
contact the practice as soon as possible.
For more information about keeping your
healthcare records safe and secure please
visit
https://www.nhs.uk/NHSEngland/thenhs/reco
rds/healthrecords/Documents/PatientGuidanc
eBooklet.pdf

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About You

Your Name
Your Address
I give consent to sharing my medical information with
MM slash DD slash YYYY
What type of information can be shared?
Is this consent permanent?
I give consent for the above information to be shared through a proxy online account (to be completed for online access requests only)
I can confirm I have read and understood the ‘Consent to Share Confidential Information Online with a Third Party Reepham & Aylsham Medical Practice – Patient Information Leaflet’ information provided with this form
I can confirm I understood:  It is my responsibility to contact the practice to request a change to permissions  I can inform any clinician at any appointment to mark my record as private and/or to remove individually from my online account