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Request to Nominate a Pseudonym

Use this form to nominate a pseudonym, which is an alias or a fictitious name assumed for a particular purpose (for example, to protect your privacy), to be held in the National Cancer Screening Register (NCSR). Once your request has been processed:

  • We will use your pseudonym in place of your legal name for all letters, notifications and contact made through the NCSR for the bowel or cervical screening program.
  • Your request will not change your name as it is currently recorded with Medicare.
  • Your healthcare providers and pathology laboratories will be restricted from viewing your screening record online, however they will be able to access your screening information when they call the NCSR Contact Centre.
  • We will use your pseudonym for all correspondence sent to your healthcare provider – you may choose to disclose your pseudonym details to your healthcare provider.
  • If you wish to register for the Participant Portal, you will initially need to use your legal name and proof of identity documents for identity verification purposes as these are required for all registrations. If you update your name or address on the Participant Portal, it will not update your pseudonym name and address.

Note: Fields marked with an asterisk (*) are mandatory.

Are you completing this form for yourself? *

Your details:

Participant details:

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

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

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.

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

This address will be used on all future screening program-related correspondence sent by the NCSR.

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.

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

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 (including my personal representative or nominated healthcare provider, if I have one) will receive correspondence, sent from the NCSR for the bowel or cervical screening program to my pseudonym name and address.
  • My personal information and screening details will be recorded under my pseudonym on the NCSR.
  • I will be responsible for notifying the NCSR when my address changes.  I may update my pseudonym name or address at any time by completing a Request to Nominate a Pseudonym form, or by calling the Contact Centre on 1800 627 701.
  • I may withdraw my request at any time by completing a Request to Withdraw a Pseudonym form, or by calling the Contact Centre on 1800 627 701.
  • I acknowledge that I am making a formal request for a pseudonym in accordance with section 14 of the National Cancer Screening Register Act 2016, and under Australian Privacy Principle 2 relating to anonymity and pseudonymity, and that this carries a different legal obligation to me requesting to nominate a preferred or alternate name.
  • For privacy reasons, I acknowledge that if any correspondence sent to the above address is returned to the NCSR, then no further bowel or cervical screening-related correspondence will be sent to me.
  • I acknowledge that any changes I make to my personal details in the Participant Portal will not update my pseudonym name and address.
  • 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 (including myself as their personal representative) will receive correspondence sent from the NCSR for the bowel or cervical screening program to their pseudonym name and address.
  • The screening participant's personal information and screening details will be recorded under their pseudonym on the NCSR.
  • I, or the screening participant, will be responsible for notifying the NCSR when their address changes and may update their pseudonym name or address at any time by completing a Request to Nominate a Pseudonym form, or by calling the Contact Centre on 1800 627 701.
  • I, or the screening participant, may also withdraw this request at any time by completing a Request to Withdraw a Pseudonym form, or by calling the Contact Centre on 1800 627 701.
  • I acknowledge that I am making a formal request for a pseudonym on behalf of the screening participant in accordance with section 14 of the National Cancer Screening Register Act 2016, and under Australian Privacy Principle 2 relating to anonymity and pseudonymity, and that this carries a different legal obligation to requesting to nominate a preferred or alternate name.
  • For privacy reasons, I acknowledge that if any correspondence sent to the screening participant's address is returned to the NCSR, then no further bowel or cervical screening-related correspondence will be sent to them.
  • I acknowledge that any changes made to the screening participants personal details in the Participant Portal will not update their pseudonym name and address.
  • I declare that I am the screening participant's authorised personal representative and have their consent to submit this form.
Acceptance of terms *