Thank you for your interest in the Derbyshire Shared Care Record.  You can use this form to tell us that you wish to Opt Out of the Derbyshire Shared Care Record, or that you are acting on behalf of a person who wishes to Opt Out.

If you opt out you will not have a record in the DSCR and information will not be available to any Health or Social Care professional using the DSCR system, even in a medical emergency.

To opt out of the DSCR you will need to:
1. Complete your details in Section A (and complete Section B if you are acting on behalf of another person)
2. Read the declaration and tick to confirm you are happy to proceed with this Opt Out
3. Submit your request

Once we have opted you out we will notify you of this by email (if you provide an email address on this form) or by post. 

Please be aware by submitting this form the information you provide here will be held electronically in order to process and evidence your request.

If you have any questions or concerns before completing this form, please contact the DSCR Privacy Officer using the details below.

Postal address: DSCR Privacy Officer, IT Services Department, Derbyshire Support, & Facilities Services Ltd, Chesterfield Royal Hospital NHS Trust, Calow, S44 5BL 
Email: crhft.enquiries.DSCR@nhs.net

If you don’t wish to be included in the Derbyshire Shared Care Record, please complete the below form.

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Address
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If you have ticked box B or C you may be asked by the Privacy Officer to provide proof of responsibilities. Please complete the section below.

Representative’s contact details:

Address