Cervical Screening - Request to Nominate a Healthcare Provider

Use this form to choose a preferred healthcare provider to receive notifications from 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 requesting to be nominated No – as a healthcare provider requesting to nominate another provider No – as an authorised personal representative

Your details:

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

Provide 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

Nominated healthcare provider details:

Given name(s) *

Family name *

Medical practice name *

Medical practice street address *

Suburb *

State *

Postcode *

Email address

Phone number

Authorised personal representative details:

To fill this form in on behalf of a screening participant your details must be recorded in the NCSR as an authorised 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 your details and submitting 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 my nominated healthcare provider will be recorded on the NCSR and be able to access details about me in relation to cervical screening.
If I see another healthcare provider for cervical screening, they will also be recorded in the NCSR and be able to access information about my cervical screening.
I may withdraw my request at any time by completing a Withdraw Previous Request form for the cervical 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.

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

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Cervical Screening - Request to Nominate a Healthcare Provider

Your details:

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Patient details:

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Nominated healthcare provider details:

Authorised personal representative details:

Requesting healthcare provider details:

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