Sharing SystmOne Information form

Your Health Record & Sharing of Information

Please read through this form carefully. It provides information about the choices you can make about sharing your health record.

Your health record includes your medical history, details about your medication and any allergies you may have. You can now choose whether to share these full medical details.

We use a secure electronic health records system called SystmOne. With your permission, this system can allow clinicians to share your full record held here with other healthcare services who are providing care for you. These other services will ask your permission to view your record.

Many organisations use SystmOne including some GP practices, out of hours services, children’s services, community services and some hospitals. Sharing your health record will help us deliver the best level of care for you.

You have two choices which allow you to control how your record is shared. You can change these choices at any time by letting the relevant Practice or Service know.

Please read the rest of the form below and fill in your choices . You may wish to keep a copy of this form, for future reference. Please contact the Patient Experience Team on 0800 279 2535

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Please note:if you have previously opted out of sharing your information via the Summary Care Record, you will still need to complete this form with your choices about sharing your health record within SystmOne.

Please complete your details below and make your choices at the bottom of the page.

Patient Name
Date of birth
MM slash DD slash YYYY

Please complete a separate form for each one of your dependants.

Sharing OUT – This controls whether your information recorded at this practice or service can be shared with other healthcare services.

Sharing IN – This determines whether or not this practice or service can view information in your record that has been entered by other services who are providing care for you, or who may provide care for you in the future.

Imagine you’re receiving care from three services: your GP, a district nurse and a smoking clinic. You want your GP and District Nurse to share information with each other and you want both of them to know your progress at the smoking clinic. However, you don’t want the smoking clinic to see any of your other medical information.

Your sharing choices at each practice or service would be:

  • The GP can share information IN and OUT.
  • The district nurse can share IN and OUT.
  • The smoking clinic can only share information OUT but not IN.
  • You can change your choices at any time. Let each practice or service know.

    Note: You can request individual entries in your record to be marked as ‘Private’. These are not shared with the rest of your record even if you choose to share out.

    I would like my health record at this practice or service to be shared with other healthcare services providing care for me.
    I would like this Practice / Service to be able to view information in my health record that has been recorded by other healthcare services.
    Practice / Service