For participants

Participant home
Participant Portal

Manage your participation

Participant forms and guides

Your privacy
For healthcare providers

Healthcare provider home
Supporting your patients

Gaining access to patient information

Important updates

Healthcare provider forms and guides

HPV positivity rates

Patient privacy
For government agencies

Government agency home
Programs and health services

HPV positivity rates

Privacy policy
About us
About the National Cancer Screening Register

News and media

Privacy policy

Frequently asked questions
Contact
Search
Order a bowel test kit

Home
Contact
Bowel Screening - Request to Defer My Next Screening Date

Bowel Screening - Request to Defer My Next Screening Date

Use this form to delay a future screening date and reminders for a period of time being sent from the National Cancer Screening Register (NCSR) for the National Bowel Cancer Screening Program (NBCSP).

_{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 *

Enter your 10-digit Medicare number only
(no spaces)

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 *

Enter your Department of Veterans' Affairs (DVA) file number only (no spaces)

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

Given name(s) *

Family name *

Date of birth *

SuMoTuWeThFrSa

27282930123456789101112131415161718192021222324252627282930311234567

Find your address *

Postal address *

Suburb *

State / Territory *

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

Reason for deferring your next screening date * Medical advice to defer Recent bowel cancer screening Recent colonoscopy Illness Living or Travelling Overseas Other (please specify)

Please describe your reason for deferring your next screening date

Defer until date *

SuMoTuWeThFrSa

27282930123456789101112131415161718192021222324252627282930311234567

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 *

SuMoTuWeThFrSa

27282930123456789101112131415161718192021222324252627282930311234567

Find your address *

Street address *

Suburb *

State / Territory *

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) *

_{Please ensure the address below matches the one registered against your medical ID number}

Find your medical practice street address *

Medical practice street address *

Suburb *

State / Territory *

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 acknowledge that I can still screen at any time and the results will be recorded on the NCSR and can be viewed by my healthcare providers.
I may withdraw my request at any time by completing a Withdraw Previous Request form for the bowel program, 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.

I acknowledge that the screening participant I am submitting this form on behalf of can still screen at any time, and the results will be recorded on the NCSR and can be viewed by their healthcare providers.
I, the participant, or their healthcare provider may withdraw this request at any time by completing a Withdraw Previous Request form for the bowel program, or by calling the Contact Centre on 1800 627 701.
I declare that I am the screening participant's authorised personal representative and have their consent to submit this form.

I acknowledge that the patient I am submitting this form on behalf of can still screen at any time, and the results will be recorded on the NCSR and can be viewed by their healthcare providers.
I, the patient, or their personal representative may withdraw this request at any time by completing a Withdraw Previous Request form for the bowel program, or by calling the Contact Centre on 1800 627 701.
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

Home

Important information

Privacy policy
Accessibility
Disclaimer
Copyright
Site map

Contact Us

1800 627 701 phone

For participants

For healthcare providers

For government agencies

About us

Search

Bowel Screening - Request to Defer My Next Screening Date

Your details:

Participant details:

Patient details:

Authorised personal representative details:

Healthcare provider details:

Important information

Contact Us