Request to Withdraw a Pseudonym

Use this form to withdraw a request for a pseudonym made to the National Cancer Screening Register (NCSR).

Once your request is processed, we will use your legal name as recorded with Medicare for all letters, notifications and contact made through the NCSR for the bowel or cervical screening program.

Healthcare providers and pathology laboratories will no longer be restricted from viewing your screening record online.

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

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

Your details:

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

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

Given name(s) (legal names) *

Family name (legal name)*

Date of birth *

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

The address below will be used on all future screening program-related correspondence sent by the NCSR.

Postal address *

Suburb *

State *

Postcode *

Nominated pseudonym given name(s)

Nominated pseudonym family 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 *

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 acknowledge that I (including my personal representative or nominated healthcare provider, if I have one) will receive correspondence, sent from the NCSR for the bowel or cervical screening program to my legal name as recorded with Medicare.
My personal information and screening details will be recorded under my legal name on the NCSR.
I may request for a pseudonym at any time by completing a Request to Nominate a Pseudonym webform, or by calling the Contact Centre on 1800 627 701.
I acknowledge that I am making a formal request to withdraw a pseudonym in accordance with section 14 of the National Cancer Screening Register Act 2016, and under Australian Privacy Principle 2 relating to anonymity and pseudonymity.
I declare that I am the screening participant and submitting this form on my own behalf.

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

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Request to Withdraw a Pseudonym

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