Lung Screening - Request to Opt Out

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

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:

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

Reason for opting out * Not interested Privacy concerns Medical advice not to participate 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 *

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 not be contacted or be sent any further correspondence from the NCSR for the NLCSP. I can still undergo a lung cancer screening test at any time through a healthcare provider. No further lung cancer 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 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 not be contacted or sent any further correspondence from the NCSR for the NLCSP. The participant can still undergo a lung cancerscreening test at any time through a healthcare provider. No further lung cancer screening information about the participant will be recorded on the NCSR. The participant’s healthcare providers will see that they have opted out but will not be able to access their screening details.
I, the participant, or their healthcare provider may withdraw this request at any time by completing a Resume Participation 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 not be contacted or sent any further correspondence from the NCSR for the NLCSP. The patient can still undergo a lung cancer screening test at any time. No further lung cancer screening information about them will be recorded on the NCSR. The patient's healthcare providers will see that they have opted out but will not be able to access the patient's screening details.
I, the patient, or their personal representative may withdraw this request at any time by completing a Resume Participation 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 Opt Out

Your details:

Participant details:

Patient details:

Authorised personal representative details:

Healthcare provider details:

Important information

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