Early Release of Superannuation on Specified Compassionate

Early Release of Superannuation on
Specified Compassionate Grounds
Report by registered medical practitioner
Instructions for the applicant
If you are applying for modifications to a home and/or vehicle, you
will need to provide:
• 1 report from a registered medical practitioner.
This is not an application form. This form is a report that is
completed by medical practitioners. This report may be used for
more than 1 compassionate ground.
If you are applying for palliative care, you will need to provide:
• 1 report from a registered medical practitioner.
Reports need to be signed, dated and be no older than 6 months
from the date of your application.
If you are applying for disability aids, you will need to provide:
• 1 report from a registered medical practitioner.
Signed reports older than 6 months will not be accepted.
Depending on your circumstances, the Australian Government
Department of Human Services may need to request additional
information.
Instructions for the medical practitioner
This report will help the Australian Government Department of
Human Services determine if an applicant is eligible to access their
superannuation early.
For the purpose of this report, the applicant can be the patient or the
applicant can have a dependant who is the patient.
You are under no legal obligation to complete this report. This report
will assist the Department of Human Services to determine if the
applicant meets the eligibility criteria set out in Regulation 6.19A of
the Superannuation Industry (Supervision) Regulations 1994 and
Regulation 4.22A of the Retirement Savings Accounts Regulations
1997.
What the applicant should do
As the applicant, you need to complete the Applicant’s details section
questions 1-6 on page 3. The medical practitioner is responsible for
completing the remainder of this report. We cannot accept any
reports that have the practitioner’s section completed by the
applicant.
You will need to take this report to the medical practitioner. Please let
the practitioner know at the time of making the appointment that you
require this report to be completed to assess your eligibility for an
early release of superannuation benefits. The medical practitioner
needs to complete all sections of the form that apply to you and your
circumstances. This report may be used for more than 1 application
for an early release of your superannuation. You are responsible for
any costs in obtaining this report.
Completing this report
This report must be completed by a registered medical practitioner.
An applicant can only complete the applicant section of this report
questions 1-6 on page 3. We cannot accept reports completed by
Allied Health Professionals.
Practitioners can only comment on conditions which are specific to
their field of expertise. For example, a dental practitioner cannot
comment on palliative care.
You will need to get the completed report from your practitioner and
return it to the Early Release of Superannuation Benefits Programme
unless your practitioner returns it for you.
Under Regulation 6.19A of the Superannuation Industry (Supervision)
Regulations 1994 and Regulation 4.22A of the Retirement Savings
Accounts Regulations 1997, a person may apply for an early release
of superannuation to pay for out-of-pocket treatment expenses when
the condition can be categorised as:
• a life threatening illness or injury, or
• an acute or chronic pain, or
• an acute or chronic mental illness, or
• a severe disability, or
• a terminal illness.
What the applicant needs to provide
You need to provide an application form for the relevant expenses
you are applying for:
• Early Release of Superannuation on Specified
Compassionate Grounds Palliative Care or Funeral
Expenses form (MO013)
• Early Release of Superannuation on Specified
Compassionate Grounds Medical, Dental or Transport form
(MO014)
• Early Release of Superannuation on Specified
Compassionate Grounds Home or Vehicle Modifications
form (MO015).
Treatments which can be considered under medical grounds are
limited to those which are legal in Australia, medical in nature and
which cannot be obtained in a reasonable timeframe through the
public health system.
You will also need to provide quotes or unpaid invoices for the
expenses you are applying for and a copy of this medical report.
Depending on what ground(s) you are applying under, you may need
to provide more than 1 report.
If you are applying for medical treatment or transport, you will need
to provide:
• 1 report from a registered medical practitioner, and
• 1 report from a registered medical specialist.
MO017.1501 (formerly 8495)
1 of 6
Early Release of Superannuation Benefits Programme
definitions
Life threatening refers to a condition which without recommended
treatment within 12 months the patient will die or suffer irreversible
degeneration of a condition that, if left untreated, would result in
premature death.
Acute refers to the rapid onset or progress of a condition and
suggests that the condition has progressed to a stage where there is
some urgency for treatment.
Chronic refers to a condition having a long duration and less rapid
change. The condition may be stable for some time or be one which
is characterised by relapse or remission. It would usually refer to a
condition of at least 3 months duration.
Severe disability refers to a severe physical or mental impairment
which either temporarily or permanently seriously limits 1 or more
functional capacities such as mobility, communication, self-care and
causes substantial functional limitation in every day activities.
Terminal illness refers to an illness or injury that is likely to result in
death.
Disability aids can include, but are not limited to, dentures, hearing
aids, prosthetics or optical aids.
For more information
For more information, go to our website
humanservices.gov.au/earlysuper or for assistance completing
this form call 1300 131 060 Monday to Friday, between 9.00 am and
5.00 pm Australian Eastern Standard Time.
Note: Call charges apply – calls from mobile phones may be charged
at a higher rate.
www.
Filling in this form
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this
with a ✓ or 7
• Where you see a box like this
Go to 5 skip to the question
number shown. You do not need to answer the questions in
between.
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 form to:
Department of Human Services
ERSB Programme
PO Box 1001
TUGGERANONG DC ACT 2901
MO017.1501 (formerly 8495)
2 of 6
Early Release of Superannuation on
Specified Compassionate Grounds
Report by registered medical practitioner
Applicant’s details
Patient’s details
8 Patient’s name
For the purpose of this report, the applicant can be the patient or
the applicant can have a dependant that is the patient.
Only progress with this report if you (or the patient) are claiming
the early release of superannuation benefits on one or more of the
following compassionate grounds:
• Medical or dental treatment
• Medical transport
• Home or vehicle modifications to accommodate a severe
disability
• Palliative care
• Disability aids
Dr
Mr
Family name
Miss
Ms
Ms
Other
Second given name
9 Patient’s date of birth
/
Mrs
Miss
First given name
1 Applicant’s name
Dr
Mr
Family name
Mrs
Other
/
10 Patient’s sex
Male
Female
11 Patient’s address
First given name
Second given name
Postcode
12 Patient’s Centrelink Reference Number (if known)
2 Applicant’s date of birth
/
/
3 Applicant’s address
13 What is the applicant’s relationship to the patient?
14 Did the applicant provide ongoing care or support to your
Postcode
patient for an extended period of time before the onset of their
condition?
No
Go to 17
Yes
4 Applicant’s contact phone number
(
)
5 Applicant’s Centrelink Reference Number (if known)
15 How long has care been provided before the onset of your
patient’s current condition?
6 Do you give us permission to discuss your application with your
weeks
medical practitioner?
No
Yes
16 What type of care or support have they provided?
The remainder of this report must be completed by
the medical practitioner
7 Is the applicant also the patient?
No
Yes
Go to 17
MO017.1501 (formerly 8495)
3 of 6
17 Is there a worker’s compensation claim relating to the patient’s
22 Why does the patient need this medical treatment?
condition?
No
Yes
The applicant needs to attach details which show
which expenses are or are not covered by a worker’s
compensation claim.
23 Is the medical treatment readily available through the public
18 What is the applicant applying for?
health system?
No
Yes
An applicant may apply for more than 1 compassionate
ground.
Tick ALL that apply
24 Is the applicant also applying for medical transport expenses?
Medical/Dental
treatment
Go to 19
Medical transport
Go to 25
Disability aids
Go to 32
Medical transport
Home/Vehicle
modifications
Go to 32
25 Does the patient require medical transport to access medical
Palliative care
Go to 37
No
Yes
treatment?
No
Go to 31
Yes
The applicant may not be eligible for
an early release of superannuation.
For eligibility criteria, go to our
website
humanservices.gov.au/earlysuper
Go to 42
None of the above
26 What is the medical treatment needed for?
www.
Medical/Dental treatment
19 What is the medical treatment needed for?
Tick ALL that apply
A life threatening
illness or injury
An acute or
chronic pain
An acute or
chronic mental
illness
None of the above
The applicant may not be eligible for
an early release of superannuation.
For eligibility criteria, go to our
website
humanservices.gov.au/earlysuper
Go to 31
www.
27 What is the name of the condition?
The applicant may not be eligible for
an early release of superannuation.
For eligibility criteria, go to our
website
humanservices.gov.au/earlysuper
Go to 24
28 Which type of transport is medically appropriate?
Tick ALL that apply
Car
Taxi
Bus
Train
Plane
Other Give details below
www.
20 What is the name of the condition?
21 What treatment is required for the condition?
Treatment
Tick ALL that apply
A life threatening
illness or injury
An acute or chronic
pain
An acute or chronic
mental illness
A severe disability
A severe disability
None of the above
Go to 31
Medicare number
29 Are there any medical restrictions on the type of transport
needed?
No
Yes
Give details below
MO017.1501 (formerly 8495)
4 of 6
30 Complete the following sections for each treatment location
Treatment location 3
Treatment location 1
Address where the treatment is provided
Address where the treatment is provided
Postcode
Postcode
How often must your patient attend medical treatment?
Complete ONE only with a NUMERAL
How often must your patient attend medical treatment?
Complete ONE only with a NUMERAL
times per week
times per month
times per year
times per week
times per month
times per year
How many weeks will your patient require treatment?
How many weeks will your patient require treatment?
The maximum period that can be considered is 52 weeks
of medical treatment.
The maximum period that can be considered is 52 weeks
of medical treatment.
If additional treatment locations need to be listed,
attach a separate sheet with details.
Treatment location 2
Address where the treatment is provided
31 Is the applicant also applying for disability aids or home/vehicle
modifications?
No
Go to 36
Yes
Postcode
How often must your patient attend medical treatment?
Complete ONE only with a NUMERAL
times per week
times per month
times per year
weeks
weeks
Disability Aids and Home/Vehicle Modifications
32 Does the patient have a severe disability?
No
Yes
Go to 36
33 What is the name of the condition?
How many weeks will your patient require treatment?
The maximum period that can be considered is 52 weeks
of medical treatment.
34 What personal aids or modifications does the patient require to
accommodate this severe disability?
weeks
35 How will the personal aids or modifications assist the patient
with their severe disability?
36 Is the applicant also applying for palliative expenses?
No
Yes
MO017.1501 (formerly 8495)
5 of 6
Go to 42
Palliative care
Provide additional comments, if required
37 Has the patient been diagnosed with a terminal illness?
Go to 42
No
Yes
38 What is the name of the condition?
39 What palliative care is required?
40 Why is the palliative care required?
41 What is the estimated timeframe that the patient will require a
service provider to give palliative care?
Privacy notice
The maximum period that can be considered is 52 weeks
of palliative care.
51 Your personal information is protected by law, including the
Privacy Act 1988, and is collected by the Australian Government
Department of Human Services for the assessment and
administration of payments and services.
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 of Human Services will manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.
weeks
Registered medical practitioner’s details
42 Dr
Mr
Family name
Mrs
Miss
Ms
Other
First given name
www.
Registered medical practitioner’s declaration
43 Professional qualifications
52 I declare that:
• the information I have provided in this form is complete and
correct.
• I have completed the medical practitioner’s section in this
form in full.
• I have discussed the content of this report with the
applicant/patient.
I understand that:
• giving false or misleading information is a serious offence.
Medical practitioner’s signature
44 Australian Health Practitioner Regulation Agency (AHPRA)
registration number
45 Provider number
46 Overseas provider number
47 Practice name
Date
/
48 Practice address
Medical practitioner’s stamp
Postcode
49 Practice phone number
(
)
50 The applicant needs to provide evidence of the medical
expense(s). Quotes can be no older than 6 months from the
date of this application. Unpaid invoices can be no older than
30 days from the date of this application.
MO017.1501 (formerly 8495)
/
6 of 6
Reset form
Print form