Statutory Declaration - Section 23A Statement Form

MO023.1508 (formerly 2101)
1 of 3
Commonwealth of Australia
Statutory Declaration
Statutory Declarations Act 1959
Read these instructions carefully before completing.
Purpose of this form
The injured person (or claimant) may give this statement to the
Australian Government Department of Human Services only if
declaring that:
a Notice of past benefits has never been issued in relation
to the case for compensation. The Commonwealth has paid
no eligible benefits in respect of services and care rendered or
provided in the course of treatment for, or as a result of, the
injury or illness
or
a Notice of past benefits has previously been issued, but
had expired at the time of judgment or settlement. Other
than those set out in the most recent Notice of past benefits
issued, the Commonwealth has paid no further eligible benefits
in respect of services and care rendered or provided in the
course of treatment for, or as a result of, the injury or illness.
Eligible benefits include past Medicare benefits, nursing home
benefits, residential care or home care subsidies.
Instructions
Only 1 of the above statements may be declared.
If the injured person (or claimant) is declaring 1 of the above
statements, then the statement must be forwarded to the
Department of Human Services with the Notice of Judgment or
Settlement form (MO022).
This Statutory Declaration is not required where neither of the above
statements apply.
For more information
For more information about Medicare Compensation Recovery, go to
our website
www.humanservices.gov.au/medicarecompensationrecovery or email
compensation.recover[email protected].au or call 132 127
Monday to Friday, between 8.30 am and 5.00 pm, Australian Eastern
Standard Time.
Note: Call charges apply – calls from mobile phones may be charged
at a higher rate.
Filling in this form
Please use black or blue pen
Print in BLOCK LETTERS
Mark boxes like this with a or 7
Returning your form
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Send the completed Statutory Declaration to:
Department of Human Services
Compensation Recovery
GPO Box 4104
SYDNEY NSW 2001
or
Fax: 02 9895 3200
Privacy notice
Your personal information, and the personal information of others
that you provide, is protected by law, including the
Privacy Act 1988. The Australian Government Department of Human
Services (the department) collects personal information about the
claimant, the claimant’s legal representative and relevant contacts of
the compensation payer dealing with the claimant’s compensation
claim. This information is required for the purposes of administering
Medicare Compensation Recovery in accordance with the
Health and Other Services (Compensation) Act 1995.
The department may disclose the claimant’s personal information
to the claimant’s legal representative or the relevant compensation
payer for these purposes, and to the Department of Social Services
in relation to any services provided to the claimant under the
Aged Care Act 1997.
Your information may be used by the department or given to other
parties for the purposes of research, investigation or where you have
agreed or it is required or authorised by law.
You can get more information about the way in which the
department will manage your personal information, including our
privacy policy, at www.humanservices.gov.au/privacy or by requesting a
copy from the department.
Section 23A Statement
Page 1/3
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Statutory Declaration - Section 23A Statement Form PDF

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