Lung 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 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 requesting to be nominated No – as a healthcare provider requesting to nominate another provider No – as an authorised personal representative

Your details:

Participant details:

Patient details:

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

Medicare 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:

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

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

Nominated healthcare provider details:

Given name(s) *

Family name *

Medical practice name *

Medical practice street address *

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

Suburb *

State *

Postcode *

Email address

Phone number

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

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 *

Please describe your relationship to the participant *

Requesting healthcare provider details:

If you are filling this form in as a healthcare provider to nominate another 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 my nominated healthcare provider will be recorded on the NCSR and be able to access details about me in relation to lung cancer screening.
If I see another healthcare provider for lung cancer screening, they will also be recorded in the NCSR and be able to access my information.
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 nominated healthcare provider will be recorded on the NCSR and will be able to access details about the screening participant in relation to lung cancer screening.
If the participant sees another healthcare provider for lung cancer screening, they will also be recorded in the NCSR and be able to access the participant's information.
I, or the screening participant, 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 I am requesting to be the nominated healthcare provider for this patient.
I will be recorded on the NCSR and will be able to access details about this patient in relation to their lung cancer screening.
If this patient sees another healthcare provider for lung cancer screening, that healthcare provider will also be recorded in the NCSR and be able to access this patient's information.
I, or the patient, 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.

I acknowledge that I am nominating another healthcare provider for this patient.
That provider will be recorded on the NCSR and be able to access details about this patient in relation to their lung cancer screening.
If this patient sees another healthcare provider for lung cancer screening, they will also be recorded on the NCSR and access this patient's information.
I, another healthcare provider, or the patient, 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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Cervical program

Lung program

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Lung Screening - Request to Nominate a Healthcare Provider

Your details:

Participant details:

Patient details:

Patient details:

Nominated healthcare provider details:

Authorised personal representative details:

Requesting healthcare provider details:

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