Cervical Screening - Request to Opt Out

Use this form to opt out of all participation in the National Cancer Screening Register (NCSR) for the National Cervical Screening Program (NCSP).

Before filling in this form, please read important information about opting out of the NCSR.

_{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:

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

Reason for opting out * Not interested Privacy concerns Other

Please describe your reason for opting out

Confirmation I wish to receive confirmation that this has been actioned.

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 will not be contacted or be sent any further correspondence from the NCSR for the NCSP. I can still undergo a cervical screening test at any time through a healthcare provider.
No further cervical screening information about me will be recorded on the NCSR. My healthcare providers can be informed that I have opted out but will not be able to access my screening details.
I may withdraw my request at any time by completing a Resume Participation 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 Opt Out

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Participant details:

Patient details:

Authorised personal representative details:

Healthcare provider details:

Important information

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