Skip to main content

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) or National Cervical Screening Program (NCSP). 

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:

Please help us identify you with one of the following *

Participant details:

Please help us identify the participant with one of the following *

Patient details:

Please help us identify your patient with one of the following *

The number displayed at the upper right of your bowel screening letter or lower left of your cervical screening letter

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

If you would like the participant to be contacted if there are any issues processing this request, please provide their email address.

If you would like your patient to be contacted if there are any issues processing this request, please provide their email address.

Personal representative details:

Relationship to you *
Relationship to the participant *
Relationship to your patient *
Select the program(s) you are nominating a personal representative for: *
Select the program(s) you are nominating a personal representative for: *
Select the program(s) where you will act on the participant’s behalf: *

Requesting healthcare provider details:

If you are filling this form in as a healthcare provider on behalf of a patient, please provide your name and contact information.

We require an email address so we can contact you if there are any issues processing your request.

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.

I acknowledge:

  • I am requesting to nominate a personal representative for this patient.
  • The nominated personal representative will be recorded on the NCSR, will be able to access details about this patient held by the NCSR and can make requests to the NCSR on their behalf.
  • The NCSR requires supporting documentation to verify the patient’s relationship with a personal representative acting in a legal capacity (such as under Legal Guardianship, Power of Attorney or Trusteeship) and will contact the personal representative with instructions to provide supporting documentation.
  • Upon processing this form, any previously nominated personal representatives will be replaced.
  • I, another healthcare provider, the patient, or their personal representative, may withdraw this 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 patient’s healthcare provider and have their consent to submit this form.

I acknowledge:

  • As the nominated personal representative, I will be recorded on the NCSR, have the ability to access details about the screening participant held by the NCSR and make requests to the NCSR on their behalf.
  • If I am acting as a personal representative in a legal capacity (such as under Legal Guardianship, Power of Attorney or Trusteeship), the NCSR requires supporting documentation to verify my relationship with the participant and will contact me with instructions to provide supporting documentation.
  • Upon processing this form, any previously nominated personal representative will be replaced.
  • I, the screening participant or their healthcare provider, may withdraw this 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 requesting to be the screening participant’s authorised personal representative and have their consent to submit this form.

Acceptance of terms *