Health Information Exchange opt-out form

Request for my clinical information to be withheld from the health information exchange (HIE)

What does it mean if I do not have an HIE record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

By not having an HIE record this will not prevent you from receiving care from either your GP or the trust.

The benefits of having an HIE record include:

  • improved quality of care
  • improved patient safety
  • improved patient experience
  • less delays in care 

Opt-out form

If you DO NOT want a Health Information Exchange Record please complete this form fully

If you are filling out this form on behalf of another person or a child, please ensure you fill out their details in section A and your details in section B

Section A

Section B

If completing the form on behalf of another person or a child

Please enter the word you see in the image below:

To learn how we collect sensitive information on this website please read the section titled 'sending information to our site' in our terms and conditions. To learn how we use information gathered while providing your healthcare please read our privacy statement.