Caldicott Guardian Registration Certificate - Change of details

Please make the following changes to my organisation’s entry in the

NHSCaldicott Guardian Register.(fields marked * are mandatory)

Section 1: Change Type:

*ENTRY (please tick): Name Address Contact Details

ORGANISATION TYPE: ………………………………………………………………………

*ORGANISATION NAME: ……………………...... ………

ORGANISATION CODE: ………………………………………………………………………

Section 2: Amended Caldicott Guardian information:

*NAME: …………………………………………………………………..………

*JOB TITLE: ………………………………………………………………………………….………

*ADDRESS: ……………………………………………………………………………………………

………………………………………………………………………………...... ………

…………………………………………………POST CODE: …………………………….………

*TEL: ………………………………… FAX: ……………………………………………………

*EMAIL: ………………………………………………………………………………...... ………

Section 3: Declaration:

PRINT: ……………………….. SIGNED: …………………….. (Caldicott Guardian – as named

in Section 2)

DATE: ………………………………..

PRINT: ………………………………... SIGNED: ….…………………….. (Authorised Signatory –see reverse for guidance)

DATE: ………………………………..

PLEASE NOTE: By signing and returning this form you agree to your contact details being published to the wider NHS within the national register of Caldicott Guardians.

Please send the HARD copy of the completed form to:

The Exeter Helpdesk (CG), Health & Social Care Information Centre, Hexagon House, Pynes Hill, Exeter, EX2 5SE

Completing the form - Guidance notes:

All sections of the form marked with * are mandatory fields and the form cannot be processed without this information.

Section 1:

Please indicate the Organisation name and ODS code of the Organisation that the Caldicott Guardian is to be amended against.

Section 2:

Please provide details of the person that you wish to amend on the Caldicott Guardian register.

Section 3:

The Declaration: By signing and returning this form you agree to your details being published to the wider NHS within the national register of Caldicott Guardians.

The person who is going to be amended on the register should print, sign and date the form.

The form must be signed off by an authorised signatory as listed below:

Organisation / Authorised Signatory
Non NHS / Chief Executive / Director (or equivalent)
NHS Trust / Chief Executive
CCG / Chief Operating Officer/Chief Accountable Officer
CSU / NHSCB Caldicott Guardian / NHSCB Board member
NHS CB Region / NHSCB Caldicott Guardian / NHSCB Board member
Area Team / NHSCB Caldicott Guardian / NHSCB Board member
NHS Commissioning Board / Chief Executive
Executive Agency / Chief Executive
DMIC / HSCIC Caldicott Guardian / HSCIC Board member

Version 4. February 2012