Cervical Screening - Request to Withdraw a Previous Request

Use this form to withdraw a previous request made to the National Cancer Screening Register (NCSR) for the National Cervical Screening Program (NCSP).

_{Note: Fields marked with an asterisk (*) are mandatory.}

Are you completing this form for yourself? * Yes No – as a healthcare provider on behalf of a patient No – as an authorised personal representative on behalf of someone else

Your details:

Participant details:

Patient details:

Medicare, NCSR ID, or Department of Veterans' Affairs (DVA) number *

Medicare number *

NCSR ID number *

The number displayed at the upper right of your bowel screening letter or lower left of your cervical screening letter

Department of Veterans' Affairs (DVA) number *

Provided given name(s) and family name, as recorded with Medicare:

Given name(s) *

Family name *

Date of birth *

Postal address *

Suburb *

State *

Postcode *

We require an email address so we can contact you if there are any issues processing your request. If you prefer not to share your email or do not have one, please call our Contact Centre at 1800 627 701.

Email address *

Phone number

If you would like the participant to be contacted if there are any issues processing this request, please provide their email address.

Email address

Phone number

If you would like your patient to be contacted if there are any issues processing this request, please provide their email address.

Email address

Phone number

Select the request(s) you want to withdraw: * Withdraw request to defer screening date Withdraw request to cease contact and correspondence Withdraw request to nominate healthcare provider Withdraw request to nominate a personal representative Withdraw request to nominate a preferred name

Authorised personal representative details:

To fill in this form as an authorised personal representative, your details must be registered with the NCSR as the screening participant’s personal representative, otherwise we will not be able to process your request.

If you are unsure, please call our Contact Centre on 1800 627 701 before filling in this form.

Given name(s) *

Family name *

Date of birth *

Postal address *

Suburb *

State *

Postcode *

We require an email address so we can contact you if there are any issues processing your request.

Email address *

Phone number

What is your relationship to the participant *

Please describe your relationship to the participant

Healthcare provider details:

If you are filling in this form as a healthcare provider on behalf of a patient, please provide your name and contact information.

Given name(s) *

Family name *

Medical practice name *

Please provide a medical ID number *

Medicare Provider number *

State and Territory Access Number (STAN) *

Medical practice street address *

Please ensure the address matches the one registered against your medical ID number

Suburb *

State *

Postcode *

We require an email address so we can contact you if there are any issues processing your request.

Email address *

Phone number

Any personal information provided to the NCSR, including your email address, will only be used to assist in processing this request.

For more information on how personal information is handled, view the privacy policy and frequently asked questions.

I declare that I am the screening participant and submitting this form on my own behalf.

I declare that I am the screening participant's authorised personal representative and have their consent to submit this form.

I declare that I am the patient's healthcare provider and have their consent to submit this form.

Acceptance of terms * I have read, understood and agree to these statements

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Cervical Screening - Request to Withdraw a Previous Request

Your details:

Participant details:

Patient details:

Authorised personal representative details:

Healthcare provider details:

Important information

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