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Information Sharing Agreement between

[Organisation name] and Suffolk GP Federation CIC, for the Sharing of Information
concerning [Service in question]

This Information Sharing Agreement defines the arrangements for processing person
identifiable information between [Organisation name] and Suffolk GP Federation CIC:

1.0 Responsible Officer


Full name of officer responsible for managing this agreement
[Name], ([Organisation Name])
Mrs Julie Smith (Operations Director, Suffolk GP Federation CIC)

2.0 Name of Organisation

Full name & address of the organisations party to this agreement.


Suffolk GP Federation CIC [Organisation Name & address]
Riverside Clinic
2 Landseer Road
Ipswich, Suffolk
IP3 0AZ

3.0 DPA Registration Number

Z1409359 – Suffolk GP Federation CIC Zxxxxxxx – xxxxxx

4.0 Is patient consent obtained to share their personal information?

Yes / No

5.0 Are patients exposed to Fair Process Notices?


e.g. posters and/or leaflets that explain how and who you are going to share patient
information with?

Yes / No

6.0 What personal information is shared?

Patient Name
Patient Address
Patient Date of Birth
Patient NHS Number
GP Practice/GP
Date referral received
Date/s and details of appointment/s booked

Suffolk GP Federation CIC


Registered in the UK. Registration number: 06183049
Registered address:
Riverside Clinic, 2 Landseer Road, Ipswich, Suffolk, IP3 0AZ, UK
Tel: 0845 2413313 Email: admin@suffolkfed.org.uk Web: www.suffolkfed.org.uk Reg. No: 1-140317426
7.0 What is the business reason for sharing person identifiable information?

Short description required

8.1 For PII classed as personal information, please state the applicable conditions from
schedule 2 of the DPA, that will allow lawful sharing.

2a) The processing is necessary for the performance of a contract to which the data subject
is a party

8.2 For PII classed as sensitive information, please also state the applicable conditions
from schedule 3 of the DPA, that will allow lawful sharing.

9.0 When and how often is the information to be shared?


e.g. on an ad hoc basis, or at the beginning of every quarter Please give details.

10.0 What media is used for transferring the data (format and method)?

How will the information be transferred and it what format?


(e.g. documents by fax, post, courier, messages by answer machine, encrypted CD by
special delivery etc). Please give details.

Suffolk GP Federation CIC


Registered in the UK. Registration number: 06183049
Registered address:
Riverside Clinic, 2 Landseer Road, Ipswich, Suffolk, IP3 0AZ, UK
Tel: 0845 2413313 Email: admin@suffolkfed.org.uk Web: www.suffolkfed.org.uk Reg. No: 1-140317426
11.0 How is the information to be stored?

12.0 Who will handle the data? Please state the authorised users.

Who will handle this information in order to do their job

13.0 How long will the data be held i.e. Retention period?

Any information held will not be retained for any longer than is necessary for the purpose
that it was obtained for. Please give details.

14.0 What is the destruction process?

How will the information be destroyed when no longer required?


(e.g. shredding) Please give details.

For the purposes of allowing the exchange of personal identifiable information for business
reasons, whilst ensuring that the information is exchanged and transferred in a safe and
secure manner, in order to protect individuals’ privacy and confidentiality at all times, the
undersigned agree to adhere to the arrangements stated above, in conjunction with the
overarching Policy.

Suffolk GP Federation CIC


Registered in the UK. Registration number: 06183049
Registered address:
Riverside Clinic, 2 Landseer Road, Ipswich, Suffolk, IP3 0AZ, UK
Tel: 0845 2413313 Email: admin@suffolkfed.org.uk Web: www.suffolkfed.org.uk Reg. No: 1-140317426
On behalf of: [Organisation name]
Name: [Name], [Title]

Signed by: _______________________ Date:_____________

On behalf of: Suffolk GP Federation CIC


Name: Julie Smith, Operations Director

Signed by: _______________________ Date:_____________

Suffolk GP Federation CIC


Registered in the UK. Registration number: 06183049
Registered address:
Riverside Clinic, 2 Landseer Road, Ipswich, Suffolk, IP3 0AZ, UK
Tel: 0845 2413313 Email: admin@suffolkfed.org.uk Web: www.suffolkfed.org.uk Reg. No: 1-140317426