Lung Screening - Request to Cease Contact and Correspondence

Use this form to stop screening program-related correspondence and notifications being sent from the National Cancer Screening Register (NCSR) for the National Lung Cancer Screening Program (NLCSP).

_{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

Participant details:

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

NCSR ID number *

The number displayed at the upper right of your National Lung Cancer Screening Program letter

Department of Veterans' Affairs (DVA) number *

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

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

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 to Cease Contact and Correspondence * Not Interested Living or Travelling Overseas Privacy Concerns Other

Cease until * Cease indefinitely Cease until date

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 *

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) *

Medical practice street address *

Please ensure the address matches the one registered against your medical ID number

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

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 no longer receive any contact or correspondence from the NCSR for the NLCSP for the period of time I have nominated. Any information relating to future lung cancer screening will continue to 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 NLCSP, 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 will no longer receive any contact or correspondence from the NCSR for the NLCSP for the period of time I have nominated. Any information relating to their future lung cancer screening will continue to 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 NLCSP, 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 will no longer receive any contact or correspondence from the NCSR for the NLCSP for the period of time I have nominated. Any information relating to their future lung cancer screening will continue to 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 NLCSP, 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.

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Lung Screening - Request to Cease Contact and Correspondence

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Patient details:

Authorised personal representative details:

Healthcare provider details:

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