Patient Agreement To Sharing Information
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1
2Patient agreement to sharing information
(as part of the supply of Oxygen by the Home Oxygen Service)
Form issued by:
Unit/Surgery
Address
Contact name
Tel no.
Postcode
Patient
Name
Address
D.O.B.
NHS number
Tel/mobile no.
Postcode
E-mail
(only include if the patient agrees to email contact)
My doctor or a member of my care team has explained the arrangements for supplying Oxygen at my premises, that my
personal information will be managed and shared in line with the Data Protection Act 1998, Human Rights Act 1998, and
common law duty of confidentiality and I understand these arrangements, such that:
1.
information about my condition/condition of the patient named above* will be provided to the Home Oxygen Service
(HOS) Supplier to enable them to deliver the Oxygen treatment as per the Home Oxygen Order Form (HOOF),
2.
the HOS Supplier will be granted reasonable access to my premises, so that the Oxygen equipment can be installed,
serviced, refilled and removed (as appropriate),
3.
information will be exchanged between my hospital care team, my doctor, the home care team and other teams (e.g.
NHS administration) as necessary related to the provision, usage, and review, of my Oxygen treatment, and safety,
4.
information will also be shared with the local Fire Rescue Services team to allow them to offer safety advice at my
premises and where appropriate install/deliver suitable equipment for safety,
5.
information will also be shared with my electricity supplier/distributer where electrical devices have been installed.
6.
From
time
to
time,
I
may
be
contacted
to
participate
in
a
patient
satisfaction
survey/audit.
(delete should you wish not to participate)
7.
I understand that I may withdraw my consent at any time (at which point my HOS equipment will be removed).
* Delete as applicable
Patient’s signature
Date
(see note 4 where signed and witnessed on patient’s behalf)
I confirm that I have responsibility for the above-named patient.
Carer’s signature
Name
Relationship to
Date
patient
I confirm that I am the healthcare professional responsible for the care of this patient and I have completed this form on
his/her behalf as s/he is unable to provide/withhold consent. The patient has been given a copy of this form.
Clinician’s signature
Date
Name
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