INSTRUCTIONS
HOW TO SELF COLLECT AN HPV TEST Simply follow the step-by-step instructions below: WHAT DOES THE KIT CONTAIN? • • • •
A swab in a plastic tube A plastic ziplock bag This instruction sheet The request form provided by your health professional • A padded ‘Reply paid’ envelope
265 Faraday PO Box 178 St Carlton South P: 03 9250 Carlton South VIC VIC 3053 0300 F: 03 3053 9349 1949
MEDICARE
Given Names
PATHOLOG
Date of Birth
Previous Surnam e Is the patient Torres Strait of Aboriginal or Islander origin?
)*
)*
*Ref: wiki.cancer
.org.au/aus
tralia/Guid
elines:Cerv
ical_cancer
/Screening
In which country
to My Health
COPY REPORT S
Fax
(Complete Medicare
Appearance
LAB CO PY
where approp
riate
bleeding
No
of cervix
Yes
(specify)
Cervix
Other
partum
(specify)
CST taken by nurse Practitioner requesting No. if not practitioner
Same day colposcopy
Practition e Assignment)
r’s Signat ure
X
Request D ate
Requesting
(Section 20A of the Health Insurance approved pathology practitioner Act 1973). I assign my right to who will render Practition er only (please the requested benefits to the tick). Reason pathology service(s) patient unable to sign.
Date
Date Name DOB
Date
MEDICARE ASSIGNMENT
Practitioner (Provider number, Surname, Initials and
• If possible, avoid taking the sample during your monthly period
• Get into a comfortable position as shown above while holding the swab in your hand
/ / Address)
Patient status or when the at the time of the specimen was service collected
Private patient or approved in a private hospital day hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
X
Name
Date
DOB
Name
Yes No
/ /
Date
Date
Name DOB
265 Faraday PO Box 178 St Carlton South VIC 3053 P: 03 9250 Carlton South VIC 3053 0300 F: 03 9349 1949 Your
Patient Surnam e
Patient’s Signature
• Undress from the waist down
(specify)
Normal Abnormal
site
Pregnant/Post Hysterectomy IUCD
By Time:
Bulk Bill
Abnormal
Specimen
born?
(please specify)
TO:
Complete patient name and date of to attachin birth prior g specime PLACE LABEL n. If more than VERTICALLY write patient 3 specimens details on additional specimens
3
was the patient
Does the patient speak a English at home? (If morelanguage other than indicate the than one language one that is , spoken most No, English often) only Yes, other
Record
Name
BIOLOGICAL SUBSTANCES CATEGORY B
Do not send
Urgent Phone Phone/Fax No. Private Schedule Vet Affairs No.
DOB
Emergency Contact Numbers: Business hours: (03) 9250 0300 After hours: 0427 308 373
Clinical Notes
UN3373
Tick only
Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Not Aborigin al or Torres Strait Islander
(indication
POSITION:
• Remove the swab out of its plastic tube, just twist and pull it
DOB
doctor The Royal College Pathologists Accredited pathologis has recommended for of Australasia t on clinical that you use with NPAAC compliance MEDICARE grounds, Standards a Medicare VCS Pathology. You CARD and ISO 15189 are free to rebate will choose your only be payable Given Names if that pathologisown pathology provider. t performs the service. However, if your doctor You should discuss this has specified a particular Gender with your doctor. Date of
NUMBER
4
5
TAKING THE SAMPLE:
TAKING THE SAMPLE (continued):
RETURN TO PLASTIC TUBE:
• Gently spread open the folds of skin at the vaginal opening with your other hand
• Rotate the swab gently for 10-30 seconds
• Place the swab into the plastic tube
• There should be no pain or discomfort
• Tightly screw the cap onto the tube
Patient Ad dress
Tests Reques ted
PAT IE N
Birth
Your Referen ce
T COPY
Privacy Note: administratio The information n of government provided will Health Insurance be used to health programs, assess Act 1973. associated and may be any Medicare benefit with this claim, The information payable for or as authorised may be disclosedused to update enrolment the to the Department by law. records. Its services rendered and collection of Health is authorised to facilitate the proper and Ageing by provisions or to a person of the in the medical practice
Telephone
(Home)
Telephone
(Business)
Requesting Practitioner (Provider number , Surname, Initials and
Address)
Patient status the specimen at the time of the service or was collected when Private
patient in a private hospital Private patient or approved in a recognised day hospital A public patient hospital in a recognised Outpatient hospital of a recognised hospital
Yes No
MEDICARE ASSIGN
(Section 20A MENT of the Health Insurance Act I assign my right to benefits 1973). practitione to the approved r who will pathology render the requested pathology service(s)
Patient’s Signatu
re
X
Date
/ / Path_Pub_3
V9
• Insert the swab into your vagina directed towards your lower back about two inches (5cm), half the length of a finger. This is similar to how you would insert a tampon
* This image is adapted from Garrow SC et al. The diagnosis of chlamydia, gonorrhoea, and trichomonas infections by self-obtained low vaginal swabs in remote northern Australian clinical practice. Sex Transm Infect. 2002 Aug; 78 (4):278-81
• Finish by washing your hands with soap and water
>> Instructions overleaf on how to pack and post the sample...
© VCS Foundation Ltd. 2020
Follow up HPV tests L.B.C only
(indication
VCS PATHOLOGY Reply Paid 178 CARLTON SOUTH VIC 3053
Y REQU EST
Your Referen ce
Tests Reques ted CST
SWAB: CARD NUMBE R
Gender
Co-test
2
Corp-Mkt-Pub-146 V1
Patient Surnam e Patient Address
1
*
INSTRUCTIONS
HOW TO PACK & POST THE SAMPLE Simply follow the step-by-step instructions below:
t send
.au/au
strali
a/Guid
MED IC ASSIG ARE NMEN
s:Cerv
ical_c
ance
ening
TO:
langu e? (If te th ag No, e one that more than e other Engl ish on is spoken one lang than uage mos (plea ly se spe Yes, t often) , cify) othe r
By Ti me:
(Com plete Med icare Assig nmen t)
X
(Secti on appro 20A of the ved
Requ
e
Nam
er nu
Tests
Requ
ested
ss
Sign
only
/Post partum
IEN
Privacy Note: adm Healtinistratio The inform atio associ h Insura n of gov ated nce Act ernme n provid nt with ed this 1973. The health will be claim, pro use or as informatiograms, andd to ass Patie author n ma may ess any y ised the spnt statu by lawbe disclo be used Medicare s ec sed to to upd . ben imen at the Private the Dep ate enr efit pay tim was patien artme olment able for colle e of th Private t in a nt of rec the cted e servi private patien Health ords. Its servic A pub ce or t in a es hospita col and lic pat recogn Ageinglection rendered when l or ient Outpa approv ised or to is author and to in a hospita tient ed day fac recogn a per ise of a l son in d by proilitate the hospita Yes No ised recogn hos the me visions pro l ised per hospita pital dical of practicthe l e (Se
MED ICARE ction I assign 20A of the ASSIG practi my right Health Ins NMEN tione uranc T r wh to bene e Ac o will
fits t rende to the ap 1973). pro r the reque ved patho sted patho logy logy servic e(s)
e
No Norm al Abno rmal Cerv
ix
ame,
Addr
ess)
Date Nam
e
T C OPY
Your
Date
t’s Si
X
EST
265 Faraday St Carlton South VIC 3053 PO Box 178 Carlton P: 03 9250 0300 F: South VIC 3053 03 9349 1949
Patient Surname
Smith
MEDICARE CARD NUMBER
Given Names
Jane Anna
Patient Address
03
SouthSouth 9349 VIC VIC 1949 3053 3053
Name
s
An
MEDI
na
CARE CARD
Gende
F
Is the Torres patien
or
hospital
Yes
Gender
F
PATHOLOGY REQUEST Date of Birth
12.06.1989
NUMB
r
ER
12
Date
.06
No
CST
Is the patient of Aboriginal or Torres Strait Islander origin?
Follow up HPV tests L.B.C only
Co-test
(indication)*
Abnormal bleeding
Torres Strait Islander Aboriginal and Torres Strait Islander Not Aboriginal or Torres Strait Islander
In which country was
Fax
T IE
the and Its services collection Ageing
(Provider number, Surname,
ame
Complete patient name and date of birth prior to attaching specimen. PLACE LABEL VERTICALLY Date If more than 3 specimens Name write patient details DOB additional specimens on
Patient’s Signature
Your Reference
)
(specify)
of
Date
X
Date
Date
Name
Name
DOB
Gender
DOB
Date of Birth
Telephone (Home)
Requesting Practitioner
/ /
Date
Name
DOB
Accredited for compliance F: 03 9349 1949 MEDICARE CARD The Royal College Pathologists with NPAAC Standards of Australasia Your doctor has recommended and ISO 15189 that you use VCS Pathology. pathologist on clinical You are free to choose grounds, a Medicare your own pathology rebate will only be payable provider. However, if that pathologist performs the service. You should if your doctor has specified a particular Given Names discuss this with your doctor.
PATIENT COPY
Yes No
MEDICARE ASSIGNMENT
(Section 20A of the Health Insurance Act 1973). I assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s)
Patient’s Signature
X
NUMBER
Your Reference
Telephone (Business )
(Provider number, Surname,
Name
X
)
Patient or when
.19
patholog your ist
t’s
Name
complian 15189Standard ce s the y provider s service. . Howeve Date You shouldr, if your of discussdoctor
r
Tel e
ph
on
e(
Birth
Practit ioner
DOB MEDI
CARE CARD
this has with specifie your da doctor. particul
Ho
(Provid er Patien
Date
Accredite with own and NPAACd for patholog ISO perform
Gende
CO
Reque sting
me )
PY Tel e
ph
Your
on
Bu
sin
ue
/
st
PATH
89
Your
OLO
nce us
B
GY
Refere
Previo
REQ
UES
T
Surna
CO
me
PY
Da
te
Date
/
/
NUMB
ER
ar
Refere nce
e(
Re q
/
status Private or approved at patient the Private specime the A public patient day in a time private hospital n Outpatient patient in of a recognised hospital was the collecte in a of service a recognised recognised hospital d Yes hospitalhospital No
ess
)
numbe r, Surnam
e, Initials
Signa
ture
and
Addres s)
Da
(specify)
Yes No
Initials and Address)
Privacy Note: The information administration of government provided will be used to assess any Medicare health programs, and Health Insurance Act may be used to update benefit payable for the services rendered enrolment records. Its associated with this 1973. The information may be disclosed and to facilitate the claim, or as authorised collection is authorised proper to the Department of by law. by provisions of the Health and Ageing or to a person in the medical practice
Patient status at the time of the service or when the specimen was collected
Private patient in a private hospital or approved day hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
NT
Address
DOB
Royal
/
(specify)
Other
Request Date
/ / Private patient a private hospital or approved day in hospital Private patient in a recognised hospital A public patient in a recognised hospital Outpatient of a recognised hospital
265 Faraday St Carlton South VIC 3053 PO Box 178 Carlton South VIC 3053 P: 03 9250 0300
Patient Surname Patient Address
Tests Requested
Yes
Normal
Patient status at the or when the specimen time of the service was collected
Initials and Address)
X
Date Name
The
Patholog College Pathologists will only y. You of Australasia be are payablefree to if thatchoose
rendered
Abnormal Cervix
CST taken by nurse Practitioner No. if not requesting practitioner
Practitioner’s Signat ure
X Requesting Practitioner
Surn
No
Appearance of cervix
Specimen site
the patient born?
Pregnant/Post partum Does the patient speak a language other than English at home? (If more Hysterectomy than one language, indicate the one that is spoken most often) IUCD No, English only Yes, other Same day colposcopy
(please specify)
By Time: (Complete Medicare Assignment)
s
Initials
and
’s re
Name
LAB COPY
Tick only where appropriate
Aboriginal
(indication)*
Record
Bulk Bill
(Section 20A of the Health Insurance Act 1973). I assign approved pathology practitioner my right who will render the requested to benefits to the Practitioner only (please pathology service(s) tick). Reason patient unable to sign.
e,
Patient Signatu
1949 3053 3053
that ,a you Medicaruse VCS e rebate
Given
UN 33 73
ended grounds
benefit enrolment payable t of records.for Health
when
sign.
South
F: South ist has 03 on recomm 9349 VIC VIC clinical
Previous Surname Tests Requested
*Ref: wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening
Clinical Notes
Urgent Phone Phone/Fax No. Private Schedule Vet Affairs No.
COPY REPORTS TO:
MEDICARE ASSIGNMENT
Date
/ /
te
/
Path_Pub_3
V9
Path_Pub_3 V9
(spec
ify)
ify)
Othe
/ /
of th colle e service cted Yes No
• Place the plastic tube into the ziplock bag • Then pack the tube and the request form into the padded reply paid envelope • Seal the envelope firmly
BER
renc
3 73 33 UN
Y 53 OG 30 OL TH 178 H VIC S PAPaid UT VC SO N ply TO Re RL CA
gnat
ure
ICAL OG BIOL
S NCE B TA RY BS SU TEGO CA
IF YOU REQUIRE A REPLACEMENT KIT, OR
: bers Num 0300 tact 9250 Con (03) 373 cy rs: 308 rgens hou 0427 Eme ines rs: Bus r hou Afte
Date
/ /
COMPLETE FORM AND CHECK LABEL: ub_
• If possible, avoid taking the sample during your monthly period
NUM
Refe
Path_P
• Your swab should be posted as soon as possible, preferably within 24 hours of collection • Store the swab at room temperature until delivery
PACKAGING:
st Da te
/ /
e Telep hone (Bus iness ) Requ estin g Prac titione r (Pro vider num ber, Su rnam e, Initi als an d Ad dress)
Patien
day
MEDI
(spec
Requ e
er
PA
Name
DOB
9250 Your Carlton Carlton patholog 0300 doctor
res s
or (Section to is authorised a person and CARE I assign to 20A in by facilitate practitio the provisions my of the ASSIG medical the ner right Health of proper practice who to benefits NMEN the Insurance will render to Act T 1973). the the approved requeste patholog d patholog y y service(s
ify)
Patie or whnt statu s at en
e)
e
hospitalhospital
LARB E CO CRORP ECY T Yes
the sp the tim Private ecim pat or app en wae rov ient in Private ed day hosa private s pital hospita patien A pub t in a l lic pat recogn ient ised hos Outpat ient of in a recogn pita ised hos l a rec ognised pital hospita l
(Hom
renc
dd
Privacy administra Note: Health associated tion The Insurance of informatio with Actgovernmen Patient this 1973. n provided the claim, t status The health Private specime or informatio will programs, as Private patient at be authorised n was used the A public patient n may and to in time a private collecte Outpatient by be may assess patient in law. disclosed of a recognised be any hospital d the used Medicare in of a recognised a recognised service to to the update hospitalor approved Departmen
(spec
e
and
YR EQU
r
py
atur
Initials
sted
LOG
Do not send to My Health
CST take n by Prac nurs e requ titioner estin N g praco. if no titio t ner
osco
tition
Surn
Reque
Refe
ious
ILS A
opriat
my
colp
X
Telep hone
Your Prev
DETA
appr
ng
site
00 F: South h VIC 30 Your DOB 03 93 VIC 30 53 patho doctor ha Date 49 19 53 logist s re 49 on cli comm nical ended The that grou Royal Nam yo nds, College a Me u use VC e Pathol dicar S Pa ogists e tho of Aus tralasia Given rebate will logy. You D OB Accre only ar Nam be pa e free to with dited for es yable ch co NP if tha oose yo and ISO AAC Sta mplianc t patho ur ow 1518 ndards e logist n patho 9 MED logy perfo prov rm ICARE ider. Gende s the serv Howe CARD ice. r You ver, if yo shou ld dis ur docto Date r ha cuss s sp of Bi this with ecified rth your a docto particu lar r.
PAT
where
bleedi
ce of cervix
imen
89
RESS
rmal
nant
erecto
me tA
Tests
DOB
Date
6.19
Spec
IUCD
PAT HO
of Bi rth
ADD
aran
e da y
Prac
mber,
Patie Sign nt’s atur e
ame
DOB
Date
e
esting
(Provid
DOB
Patie nt A ddre
ner’s
Date
e
tests
n)*
X
265 PO Farada P: Box 03 178 y St
t Surna
Tick
HPV
r/Screeni
LA
BER Patien
Abno
Preg
NUM
en
Appe
Hyst
CARD
12.0
AND
Sam
Prac titio
265 Fa PO Bo raday St P: 03 x 178 Ca Carlton 9250 rlton Sout 03
t Su rnam
IRTH
or To it Isl ande rres In w Strait r hich Islan coun der try w Does as th th e patie English e patient nt born indica at hom speak a ?
T patho Health Com Insura logy Prac pra nce tition and plete patie er on ctitioner Act 1973 who ly (p to at date of bi nt nam will ren). I assign lease my rig de tick). PLAC taching rth prio e Reas r the reque ht to be on pa nefits sted If morE LABEL specimenr pa to tient VE . e unab thology ser the RTIC write than le to AL sign. vice(s) addi patient 3 specim LY Date Date tiona en de l spec tails on s Name DOB imen s N
Patien
OF B
Strait Abor iginal Islander and Not Torres Abor iginal Stra
r/Scre
to M
y He Urge alth nt Reco rd Phon Phon e/Fa e x No Privat . e Fax Vet Af Sche fairs dule No. Bulk COPY Bill REPO
RTS
eline
)*
up
(indicatio
Aborig Strait t of Birth Torres inal IslandAborig send Urgent Aborig Strait er inal to ng origin Phone My Not or inal Health Aborig and Islande ? Private /Fax In Record No. Phone Vet inal Torres r which Affairs or Tick Torres Strait countr Does COPY Schedu only No. Fax Abnorm English the Strait Islande y was where REPOR patient le indicat Islande r at al Appea the home? speak bleedin appro By TS Bulk patien No, e the r Time: rance TO: one (If a priate English Bill g (please t born? that more languag of specify) cervix only is spokenthan e other (Compl Specim MEDI No one most langua than ete ASSIG CARE Yes, Pregna en site Yes Medica Norma often) ge, other NMEN Compl re (specify) (Section Abnorm l Hyster nt/Pos Assignm and approved 20A ectom t partum to dateete patient T Pra al IUCD of ent) attach Practitiopathologthe cti PLACE Cervix of y Health (specify) tio If ing birth name Same ne ner y practition Insurance writemore LABEL specimprior r’s only day Other than VERTIC additio patient Sig (please er who Act colpos na CST 1973). 3 specim en. tur nal tick). will (specify) details ALLY Practittaken Reque e copy renderI assign specim Date Reason reques ens (Provide the my ioner by sting Name ens on right patientrequested ting No.nurse DOB r number to Practi benefits practit if Date unable patholog , Surnamtioner not to ioner to the y service(s)
Pa ti
F
Is th Torrese patien Strait t of Abo Island rigina Abor er or l or igin igin? Torres al
ation
er.org
DATE
Gende r
only
al_cance
SU CA BST TE AN GO CE RY S B
)*
(indic
canc
al N otes
Do no
ME,
Follo w up HPV L.B.C tests only
ation
wiki.
a
F:
Given
Follow L.B.C
/australia
es:Cervic
53
(indic
*Ref:
Clinic
ICARE
es
Ann
R NA
265 PO Farada P: Box 03 y 9250178 St Carlton Carlton 0300
Jan
n)* er.org.au
Notes
/Guidelin
30
CST Co-t est
Ja ne
YOU
me
ss
sted
(indicatio wiki.canc
al
not
BIO LO GIC AL
HAT
ested
t Surna
ith
t Addre
Reque
CST
Clinic
Do
VC Re S PA CA ply P THO RL aid LO G TO N 178 Y SO UT H VIC
CK T
Requ
IMPORTANT INFORMATION
Patien
Sm
Patien
Tests Co-test
*Ref:
MED
en N am
Em Bu erge Af sines nc ter y ho s ho Cont ur ur ac s: 04 s: (0 t Nu 27 3) m 30 9250 bers 8 37 : 3 0300
ss
Date
ame
t Add re
CHE Tests
h
2
265 Fa PO Bo raday P: 03 x 178 St Carlt 9250 Carlton on So uth 0300 So F: 03 uth VI VIC 30 9349 C 3053 53 1949 Giv
t Su rn
Sm it
Name
Patien Patien
DOB
1
3 V9
• Check that the details on your form and the plastic tube are correct. • Ensure that you sign the form and record the date of collection as marked above. • Your sample does not require refrigeration. Just keep at room temperature
POST: • Deposit the reply paid envelope into an Australia Post mail box preferably within 24 hours of collection
FOR MORE INFORMATION CONTACT VCS PATHOLOGY ON PH: 03 9250 0300
• Your sample must be tested within 14 days of collection. >> Instructions overleaf on how to take a vaginal swab - DO THIS FIRST...