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 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.

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

You can either type your date of birth in (dd/mm/yyyy) or use the date picker

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

Authorised personal representative

Fill in the form below so we can process your request.

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.

You can either type your date of birth in (dd/mm/yyyy) or use the date picker

View the privacy policy

  • 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 acknowledge that 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 the NCSR apply a 'preferred name' or 'alternate name' for me.
  • 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 participant or their authorised personal representative.
  • I acknowledge that my selected request(s) will be actioned.
Acceptance of terms *