DATA REQUEST FORM USED BY PAP PROVIDERS REQUESTING
DETAILS OF LAST CERVICAL TEST FOR INDIVIDUAL PATIENTS
If you would like a list of patients who have previously had a Pap test at your practice,
including those who are now overdue for a Pap test, please use the Health Practitioner
Reminder
Service:
Pap
Data
Request
Form
at
the
following
link:
www.cancerinstitute.org.au/media/148033/e08-19619_ptr-data-request.pdf
If you would like details of the last cervical test for more than 5 and up to 10 patients please
complete the form below and Attachment 1 over page. Based on advice provided by The NSW
Ministry of Health, information will only be supplied if your patients have previously had a
cervical test with your practice, or are booked in for a test. Patients whose recommendation for
screening is outside the standard 2-yearly recall will be noted in the comments. Please contact
the Information Line if further details are required.
__________________________________________________________________________
PAP PROVIDER DETAILS – please complete all sections as detailed
First Name:
Surname:
Professional Status:
Provider Number of provider on whose behalf this request is submitted:
Practice Name:
Practice Address:
Phone:
Fax:
Email Address:
□ I declare that the patients listed have previously had a Pap Test at the above practice, or
are currently booked in for a cervical test. (Mandatory Declaration: requests without this
declaration will not be processed)
_________________________________________________
_____/______/______
Requestors Signature
Date
__________________________________________________________________________
PATIENTS’ DETAILS REQUIRED FROM PAP PROVIDERS
Please provide the patients’ details on the Attachment 1.
CERVICAL SCREENING DATA SUPPLIED BY THE NSW PAP TEST REGISTER
Please complete the form in Attachment 1 and return it to the NSW Pap Test Register by Fax:
02 8374 5695. The NSW Pap Test Register will supply the data in the format shown Attachment
2 by Fax or Email within 10 working days. Please note that the NSW Pap Test Register cannot
provide cervical screening histories for patients who have opted off from the Register.
PTR Use Only
Request IR#____________
HPRM #________________
Record Number: E14/56748
Date Received____________
Attachment 1 – Patient Details required from Pap Providers
Please complete the table below.
Patient
S/N
Patient Surname
Patient First
Name
Patient Middle
Name
Patient Date of
Birth
Pap Appointment
date
1
2
3
4
5
6
7
8
9
10
Request Page _____ of _____
Record Number: E14/56748
Attachment 2 – Data supplied by the NSW Pap Test Register
(PTR Information Line: (02) 8374 5692; 1800 671 693 (free call in NSW)
The NSW Pap Test Register will supply you with the details of the last cervical test for patients requested whose recommended
screening is outside of the standard 2-yearly recall. The information will be provided in the format below.
Please note that the Pap Test Register cannot provide cervical screening histories for patients who have opted off from the
Register. To protect patient privacy, the patients’ names will not be shown in the data released by the Register.
NSW Pap Test Register - Data Request #___________, received _______/_______/_________
Requestor's Name, Practice Name:
Requestor's Email:
Data sent by:
Patient Details
Patient
Patient
S/N
DOB
Example
01/01/1978
1
2
3
4
5
6
7
8
9
10
Record Number: E14/56748
Tel:
Standard 2yearly recall
Yes/No
No
Test Type
Cytology
Test Date
01/06/2013
, Date: _____/_____/_____
Details of Last Cervical Test
Test Result
NEGATIVE
Comments
HSIL in 2009; contact PTR Information
Line if further details are required
Record Number: E14/56748