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Fillable Printable Statutory Declaration - Section 23A Statement Form

Fillable Printable Statutory Declaration - Section 23A Statement Form

Statutory Declaration - Section 23A Statement Form

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.recovery@humanservices.gov.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
MO023.1508 (formerly 2101)
2 of 3
Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959
To be completed by the injured person (or claimant),only if (a) or (b) relates to the claim.
Section 23A of the Health and Other Services (Compensation) Act 1995 provides that the injured person (or claimant) may
submit a statement specifying:
(a) if a Notice of past benefits has never been issued in relation to the claim for compensation – that 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
(b) if a Notice of past benefits has previously been issued, but had expired at the time of judgment or settlement – that 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.
I,
1
............................................................................................................................................................................................
.................................................................................................................................................................................................
make the following declaration under the Statutory Declarations Act 1959, that as at the date of judgment or settlement
(Tick ONE only):
A Notice of past benefits has never been issued:
No Medicare benefits have been paid in the course of treatment for the injury or illness,and
I have not entered a nursing home or residential care facility or received home care services (either on a temporary
or permanent basis) as a result of the injury or illness.
or
Since the last Notice of past benefits was issued:
No further Medicare benefits have been paid in the course of treatment for the injury or illness,and
I have not entered a nursing home or residential care facility or received home care services (on a temporary or
permanent basis) as a result of the injury or illness.
and I provide the following information:
Date of birth of injured person (or claimant) ......../......../............ (day/month/year)
Department of Human Services reference or Medicare card number .......................................................................................
Date of injury or illness ......../......../............ (day/month/year)
I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under
Section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.
2
.................................................................................................................................
Declared at
3
................................................... on
4
................................................of
5
............................................................
Before me,
6
..................................................................................................................................
7
...............................................................................................................................................................................................
......................................................................................................................................................................................................
1 Insert the name,
address and
occupation of
person making
the declaration
3 Place
4 Day
5 Month and year
2 Signature of person
making the declaration
6 Signature of person
before whom the
declaration is made
(see over)
7 Full name,
qualification and
address of person
before whom the
declaration is made
(in printed letters)
* Eligible benefits means: past Medicare benefits, nursing home benefits, residential care or home care subsidies.
Note 1A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a
term of 4 years — see section 11 of the Statutory Declarations Act 1959.
Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the
Statutory Declarations Act 1959.
MO023.1508 (formerly 2101)
3 of 3
A statutory declaration under the Statutory Declarations Act 1959 may be
made before:
(1) a person who is currently licensed or registered under a law to
practise in one of the following occupations:
chiropractor
dentist
legal practitioner
medical practitioner
nurse
optometrist
patent attorney
pharmacist
physiotherapist
psychologist
trade marks attorney, or
veterinary surgeon.
(2) a person who is enrolled on the roll of the Supreme Court of
a state or territory or the High Court of Australia, as a legal
practitioner (however described).
(3) a person who is in the following list:
agent of the Australian Postal Corporation who is in charge
of an office supplying postal services to the public
Australian consular officer or Australian diplomatic officer
(within the meaning of the Consular Fees Act 1955)
bailiff
bank officer with 5 or more continuous years of service
building society officer with 5 or more years of continuous
service
chief executive officer of a Commonwealth court
clerk of a court
commissioner for affidavits
commissioner for declarations
credit union officer with 5 or more years of continuous
service
employee of the Australian Trade Commission who is:
(a) in a country or place outside Australia
(b) authorised under Paragraph 3(d) of the
Consular Fees Act 1955
(c) exercising his or her function in that place
employee of the Commonwealth who is:
(a) in a country or place outside Australia,and
(b) authorised under Paragraph 3(c) of the
Consular Fees Act 1955
(c) exercising his or her function in that place
fellow of the National Tax Accountants’ Association
finance company officer with 5 or more years of continuous
service
holder of a statutory office not specified in another item in
this list
judge of a court
justice of the peace
magistrate
marriage celebrant registered under subdivision C of
division 1 of part IV of the Marriage Act 1961
master of a court
member of Chartered Secretaries Australia
member of Engineers Australia, other than at the grade of
student
member of the Association of Taxation and Management
Accountants
member of the Australasian Institute of Mining and
Metallurgy
member of the Australian Defence Force who is:
(a) an officer
(b) a non-commissioned officer within the meaning of
the Defence Force Discipline Act 1982 with 5 or more
years of continuous service
(c) a warrant officer within the meaning of that Act
member of the Institute of Chartered Accountants in
Australia, the Australian Society of Certified Practising
Accountants or the National Institute of Accountants
member of:
(a) the parliament of the Commonwealth
(b) the parliament of a state
(c) a territory legislature
(d) a local government authority of a state or territory
minister of religion registered under subdivision A
of division 1 of part IV of the Marriage Act 1961
notary public
permanent employee of the Australian Postal Corporation with
5 or more years of continuous service who is employed in an
office supplying postal services to the public
permanent employee of:
(a) the Commonwealth or a Commonwealth authority
(b) a state or territory or a state or territory authority
(c) a local government authority with 5 or more years of
continuous service who is not specified in another
item in this list
person before whom a statutory declaration may be made
under the law of the state or territory in which the
declaration is made
police officer
registrar or deputy registrar of a court
senior executive service employee of:
(a) the Commonwealth or a Commonwealth authority
(b) a state or territory or a state or territory authority
sheriff
sheriff’s officer, or
teacher employed on a full-time basis at a school or tertiary
education institution.
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