Services Australia - Participant withdrawal of consent form

I wish to WITHDRAW my consent to release my Services Australia information to the study effective from the date below. I request that the study handles the information they have collected about me in the following way (choose one option):

I understand that:

  1. no further information about me will be collected for the study from the withdrawal date;

  2. information about me that has already been analysed and/or included in a publication by the study, may not be able to be destroyed; and

  3. choosing to withdraw from the study will not affect my access to Health Services or Government benefits.

Date of birth

Please submit this form to withdraw your consent for the release of your Medicare/PBS data. Alternatively, forms can be forwarded by email to: abcstudy@cancervic.org.au or posted to: ABC Study, Cancer Epidemiology Division, Cancer Council Victoria, 615 St Kilda Road, Melbourne VIC 3004

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Contact Us

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emailinfo@abcstudy.com.au

phone
1800 688 419

 

 

Cancer Epidemiology Division
Cancer Council Victoria
Level 8, 200 Victoria Parade,
 East Melbourne, Victoria, 3002, Australia