Request to Nominate a Personal Representative

Use this form to nominate a personal representative who can receive notifications and make requests on behalf of a screening participant for the National Bowel Cancer Screening Program (NBCSP), National Cervical Screening Program (NCSP) or National Lung Cancer Screening Program (NLCSP). 

This form requires an email address so we can contact you if there are any issues with your request. If you prefer not to share your email or do not have one, you can also nominate a personal representative by phoning us on 1800 627 701.

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

Are you completing this form for yourself? *

Your details:

Provide given name(s) and family name, as recorded with Medicare:
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Personal representative details:

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Relationship to you *
Select the program(s) you are nominating a personal representative for: *

Your privacy and acceptance of terms

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:

  • My nominated personal representative will be recorded on the NCSR, will be able to access details about held by the NCSR and can make requests to the NCSR on my behalf.
  • The NCSR requires supporting documentation to verify my relationship with a personal representative acting in a legal capacity (such as under Legal Guardianship, Power of Attorney or Trusteeship) and will contact them with instructions to provide supporting documentation.
  • Upon processing of this form, any previously nominated personal representatives will be replaced.
  • I, or my personal representative, may withdraw my request at any time by completing a Withdraw Previous Request form for the relevant screening program(s), or by calling the Contact Centre on 1800 627 701.

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

Acceptance of terms *