Instructions

Claim for
Disability Support Pension
(SA466)
Online account Completing this form online is faster and easier.
Access your Centrelink online account through myGov and select:
• Payments and claims
• then Make a claim.
If you do not have a myGov account, you can create one at my.gov.au and then link Centrelink
www.

to it.

When to use this form Use this form to claim Disability Support Pension (DSP) if you cannot claim online and you:
• are 15 years and 9 months or older and under Age Pension age, and
• are permanently blind, or
• have a disability and/or a medical condition(s), and
• are not able to work 15 hours or more a week, or be retrained for any work within the next
2 years.
You must also meet other rules like residence, income and assets.
For more information, go to servicesaustralia.gov.au/dsp
www.

You can use the pre-claim guide to see if you may be able to get DSP, go to www.

servicesaustralia.gov.au/dsppreclaimguide
Terminal illness
If you have a terminal illness with a life expectancy of less than 2 years, you can use this form
instead:
• Claim for Disability Support Pension for a terminal illness (SA494) form.

Returning this form Check that all required questions are answered and that the form is signed and dated.
Return this form and all required supporting documents.
You can do this:
• online (excluding identity documents) using your Centrelink online account. For more
information, go to servicesaustralia.gov.au/centrelinkuploaddocs
www.

• by post to
Services Australia, Disability Services
PO Box 7806
CANBERRA BC ACT 2610
• in person at one of our service centres.
Important note: You need to give us all the medical evidence and supporting documents we ask for.
If you do not, we may not accept your claim or we may reject it.

Getting help to claim If you are not sure what to do, there is support to help you claim DSP.
DSP We are here to help you
You or your nominee can visit a service centre or call us to help you complete your claim.
Go to findus.servicesaustralia.gov.au to find your closest service centre or call us on 132 717.
www.

Call charges may apply.

Help from a disability advocate
An advocate may be able to help you to claim DSP. You can find advocacy services, in your area,
by going to disabilitygateway.gov.au and searching for ‘Disability Advocacy’.
www.

You can also ask for disability advocacy help through the Disability Gateway Helpline by calling
1800 643 787, Monday to Friday, 8am to 8pm.
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Authorising a person You may want someone to help you deal with us.
or organisation to Giving a person or an organisation permission to help you do your business with us does not stop
enquire or act on your you from contacting us. You can cancel the arrangement at any time, online or by calling 132 717.
behalf We have listed the options available below. This may help you choose one that best suits your
needs:
• a person permitted to enquire can ask us questions to help you better understand your
payments and services from us
• a correspondence nominee can ask questions, make changes and act on your behalf
• a payment nominee gets your payments from us.
If you choose to have a person or organisation help you, you can:
• choose just one of these options, or
• have a correspondence nominee and a payment nominee, or
• have the same person for both.
If you want to give a person or an organisation permission to help you do your business with us,
you can do this online or complete an Authorising a person or organisation to enquire or act on
your behalf (SS313) form.
For more information, go to servicesaustralia.gov.au/authorisedrepresentative
www.

For more information Go to servicesaustralia.gov.au/dsp or visit one of our service centres.

www.

Call us on 132 717.

Call charges may apply.
Information in your language
We can translate documents you need for your claim for free.
To speak to us in your language, call 131 202.

Hearing and speech assistance

If you have a hearing or speech loss, you can use:
• the National Relay Service 1800 555 660, or
• our TTY service on 1800 810 586. You need a TTY phone to use this service
• your own Auslan interpreter. They must be nationally accredited if calling by phone.
For more details about accessibility go to servicesaustralia.gov.au/accessibility
www.

For more information about help with communication, go to servicesaustralia.gov.au and search
www.

‘other support and advice’.

Family and domestic To complete this form you may need to answer questions about your partner and/or living
violence arrangements.
If you are affected by family and domestic violence, there is help available. Call 132 850 Monday
to Friday, 8am to 5pm local time, and ask to speak to a social worker. Otherwise, you can contact
1800RESPECT (1800 737 732), a 24 hour service. If you are in immediate danger, call 000.
For more information, go to servicesaustralia.gov.au/domesticviolence
www.

Having a partner We consider you to have a partner and be a member of a couple if you are either:
• married
• in a registered relationship. This is when your relationship is registered under a law of a state
or territory.
• in a de facto relationship. This is when you and your partner are in a marriage like relationship
but you are not married or in a registered relationship.
We may still consider you a member of a couple if you are not physically living with your partner.
For example, your partner may fly-in fly-out or live away for work, like military or oil rig workers.
For more information, go to servicesaustralia.gov.au/moc
www.

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How to complete You will need to provide the following:
this form • medical evidence for each condition that affects your ability to work.
• identity documents if you have not confirmed your identity with us. For a list of acceptable
documents, go to servicesaustralia.gov.au/identity
www.

• income and assets documents. If you are not currently getting an income support payment
from us, you need to complete and return an Income and assets (SA369) form. If you ask an
accountant or financial adviser to complete the form for you, you must still sign it.
• any additional documents or forms. You will know what these documents are when you answer
a question that has a paperclip in a box. Document(s)
to provide.

Filling in this form:

There are steps in this claim form which you must complete and some you can skip.
Step 1 – your details
This step is about your personal details. You must complete this step.

Step 2 – your payment details

This step is about how you want to be paid if you You must complete this step.
can get DSP.

Step 3 – your circumstances

This step is about things that may affect your You can skip this step if:
rate of payment such as: • you are already on a Centrelink income
• your residence support payment. For more information,
• your partner (if you have one) go to servicesaustralia.gov.au and
www.

• your living arrangements search income support payment, and

• employment related income. • there are no changes to your
circumstances.

Step 4 – your independence

This step is about independence. You can skip this step if you are 21 years or
You need to do this step if you are younger than older.
21 years.
If you can get DSP, it helps us decide how much.

Step 5 – checklist and declaration

This step is: You must complete this step.
• a checklist of documents you may need to
provide
• a declaration you must complete.

Step 6 – your medical details

This step is about: You must complete this step.
• your medical condition(s)
• your treatment
• your treating health professional(s).

Step 7 – consent to disclose medical information

In this step, we ask for your consent to talk to You can complete this step – it may help us
your treating health professional(s) if we need to. assess your claim more quickly.

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Medical evidence to We need to know how your disability or medical condition affects you. This will help us work out if
support your claim for you can get DSP.
DSP We need medical evidence from your treating doctors or other health professionals. In most
cases, we need current evidence for each condition that affects your ability to work.
Give us all your medical evidence with your claim so we can assess it faster. It should support
what you have put in the medical details section of this claim form.
If you do not give us evidence, we may not be able to assess your claim. If you are having
problems getting evidence, call us on 132 717. We can talk with you about your options.
For more information about what medical evidence you may need to provide, go to www.

servicesaustralia.gov.au/dspmedicalevidence

Assessments You may need to attend one or more assessments as part of your claim for DSP.
Job Capacity Assessment
This may be done in person, by phone or video conference. You will be told if you need to attend.
For more information, go to servicesaustralia.gov.au/workcapacity
www.

Disability Medical Assessment

Not everyone who claims needs to attend. You will be told if you need to attend.
For more information, go to servicesaustralia.gov.au/dspmedicalassessment
www.

Program of support A Program of Support is a government funded program that helps people to prepare for, find and
keep a job.
To get DSP you may need to have participated in a Program of Support within the last 3 years.
For more information, go to servicesaustralia.gov.au/dspprogramofsupport
www.

While we assess If you are getting JobSeeker Payment or another payment with participation requirements, you
your claim will be exempt from looking for work while your claim for DSP is being assessed.
If you claim DSP, you may be able to get another payment while we assess your claim, such as:
• Jobseeker Payment
• Youth Allowance for job seekers.
If you would like to claim one of these payments, you can go online or call us.
If you are claiming DSP online, you can claim JobSeeker Payment as part of your online claim.
For more information, go to servicesaustralia.gov.au/jobseekers
www.

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Other payments or Mobility Allowance
services A payment to help with travel costs for work, study or looking for work if you have a disability,
illness or injury that means you cannot use public transport.
For more information, go to servicesaustralia.gov.au/mobilityallowance
www.

Carer Payment/Carer Allowance

If your disabilities, illnesses or injuries make it hard for you to care for yourself and you have
someone caring for you, they may be eligible for Carer Payment and/or Carer Allowance.
For more information, go to servicesaustralia.gov.au/carers
www.

Essential Medical Equipment Payment

A yearly payment to help with energy costs to run essential medical equipment or heating or
cooling used for medical needs.
For more information, go to servicesaustralia.gov.au/emep
www.

Pensioner Education Supplement

A payment to help with your study costs if you are studying an approved course and getting a
payment such as DSP.
For more information, go to servicesaustralia.gov.au/pensionereducation
www.

Continence Aids Payment Scheme

A yearly non-taxable payment to cover some of the cost of products that help you manage
incontinence.
For more information, go to servicesaustralia.gov.au/caps
www.

Finding other help

For more information about how to access support services for everyday life when you live with
disability, go to servicesaustralia.gov.au and search finding other help when you are living with
www.

disability.

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This page has been left blank intentionally.
 Instructions
Step 1 – your details

You must complete this step, it is about your personal details. 4 Have you been known by any other name(s)?
It helps us confirm information, such as Include:
• your name and contact details • name at birth • alias
• if you want someone to act on your behalf • name before marriage • adoptive name
• if you have, or can, claim compensation, insurance or damages. • previous married name • foster name.
• Aboriginal or skin name

No Go to next question
Filling in this form Yes Give details below
You can fill this form digitally in some browsers, or you can open it 1 Other name
in Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader,
you can print this form and complete it.
If you have a printed form:
• Use black or blue pen.
• Print in BLOCK LETTERS. Type of name (for example, name at birth)
• Where you see a box like this Go to 1 skip to the question
number shown.
2 Other name
Your personal details

1 Your Customer Reference Number (if known)

Type of name (for example, name before marriage)

2 Your name If you need more space, provide a separate sheet with details.
Mr Mrs Miss Ms Mx Other
Family name 5 Your gender
Male
First given name Female
Non-binary

Second given name

6 Your permanent address

3 Your date of birth (DD MM YYYY)

Postcode

7 Your postal address (if different to above)

Postcode

CLK0SA466 2404

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8 Read this before answering the following question. 14 Are you planning on working less hours due to your disability or
Providing a mobile phone number or an email address means medical condition(s)?
you may get SMS or emails from us. To read the terms and No
conditions, go to servicesaustralia.gov.au/em
Yes
www.

Your contact details

Home phone number 15 Are you at risk of losing your job because of your disability or
(including area code) medical condition(s)?
No
Mobile phone number
Yes
Email

16 Before you needed to make this claim, were you:

• self employed
• working as a sub contractor
9 Do you want to authorise a person or organisation to make • a primary producer (for example, a farmer, a market
enquires, make updates, act and/or get payments on your gardener)?
behalf?
No Go to next question No Go to 18
Yes Details below Yes Go to next question

You need to fill in and return an Authorising a person

or organisation to enquire or act on your behalf 17 Are you still doing this work?
(SS313) form. You can also do this online. You and the No Go to next question
person or organisation will need a Centrelink online
Yes How many hours are you working now?
account.
If you want more information or to download the form, hours per week
go towww.

servicesaustralia.gov.au/authorisedrepresentative
18 Are you currently studying (for example, school, TAFE college,
university)?
10 Before you needed to make this claim, were you working as a No Go to next question
wage or salary earner?
Yes How many hours are you studying now?
No Go to 16
Yes Go to next question hours per week

11 Was your work supported by any of the following? 19 Before you needed to make this claim, were you doing
Supported Wage System something other than paid employment or studying?

Australian Disability Enterprises provider For example:

• voluntary work • caring for someone else
Disability Employment Services provider • unemployed • parenting
• in receipt of another • recovering from an illness
None of the above payment or operation
• financially dependent on • undergoing rehabilitation.
For more information about these services, go to www.
someone else
servicesaustralia.gov.au/dsphelptowork • undertaking home duties

12 Are you still working for this employer? No Go to next question

Yes Give details below
No Go to 16
Yes How many hours are you working now?
hours per week

13 Is this a gradual return to work?

No
Yes

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20 Have you been charged with an offence and are: 27 Do you (and/or your partner) get Self-Employment Assistance?
• in prison pending trial or sentencing, or under sentence for
conviction of an offence, or No Go to next question
• undergoing psychiatric confinement? Yes
Provide a letter or other document that gives
the reference number and details of each
No Go to 23 payment.
Yes You may not be eligible for DSP. Go to next question
Before completing this claim call us on 132 717.
Go to next question

21 What is the name of the institution where you are detained? Compensation, insurance and damages

28 Read this before answering the following question.

Compensation, insurance and damages include:
22 What is your expected release date (if known)?
• workers’ compensation
(DD MM YYYY) • motor vehicle third party scheme
• criminal injuries/victims compensation
• sporting injury
23 Are you claiming DSP because you are permanently blind? • public liability
No Go to 28 • medical negligence
Yes Go to next question • personal accident and sickness insurance
• income replacement insurance.

24 Are you (and/or your partner) claiming Rent Assistance? Did you (or your partner) ever:
No Go to next question • get
• claim, or
Yes You need to complete and return an Income • been able to claim
and assets (SA369) form.
If you do not have this form, go to
www.
compensation, insurance and/or damages?
servicesaustralia.gov.au/forms No Go to 30
Go to Step 2 – your payment details on
page 10 Yes Go to next question

29 Have you (or your partner) told us about this before?

25 Are you (and/or your partner) getting a New Zealand
government payment? No You need to complete and return a
Compensation and damages (Mod C) form.
No Go to next question
If you do not have this form, go to
Yes
www.

Provide a letter or other document that gives servicesaustralia.gov.au/forms

the reference number and details of the Go to next question
payment.
Go to next question Yes Go to next question

26 Are you (and/or your partner) getting a payment from the 30 Do you (and/or your partner) get payments from an income
Department of Veterans’ Affairs? protection policy?
No Go to next question No Go to next question
Yes Yes
Provide a letter or other document that gives Provide a copy of the policy document and
the reference number and details of each the latest statement for this policy.
payment. Go to next question
Go to next question

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 Step 2 – your payment details

You must complete this step, it is about how you want to be paid 34 Are there any changes to your (and/or your partner’s)
if you can get DSP. circumstances below that you have not already told us about?
Circumstances:
• your preferred language
31 Read this before answering the following question. • if you are of Aboriginal or Torres Strait Islander Australian
descent
The Pension Supplement helps you to meet the costs of your • your accommodation
daily household and living expenses. • your living arrangements
It is automatically paid each fortnight with your regular • your partner (if applicable)
pension. You can choose to get part of the Pension • your Australian residence
Supplement on a quarterly basis. • your home
For more information, go to www.

• employment related income

servicesaustralia.gov.au/pensionsupplement • tax file number(s).
How often do you wish to get the minimum Pension
Supplement amount? No Go to Step 4 – your independence on page 24
Fortnightly Yes Go to Step 3 – your circumstances on page 11
Quarterly

32 Where do you want your payment made?

The account must be in your name. A joint account is
acceptable.
Payments cannot be made into an account used exclusively
for funding from the National Disability Insurance Scheme.
Name of bank, building society or credit union

Branch number (BSB)

Account number (this may not be your card number)

Account held in the name(s) of

33 Are you (and/or your partner) currently getting any of the

following payments?
• ABSTUDY • JobSeeker Payment
• Age Pension • Parenting Payment
• Austudy • Special Benefit
• Carer Payment • Youth Allowance.
• Disability Support Pension

No You (and your partner) need to complete and

return an Income and assets (SA369) form.
If you do not have this form, go towww.

servicesaustralia.gov.au/forms
Go to Step 3 – your circumstances on
page 11

Yes Go to next question

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 Step 3 – your circumstances

This step is about your circumstances, such as: Your residence details
• your Australian residence
• your partner (if you have one) 40 What country are you currently living in?
• your living arrangements
This is the country where you normally live on a long term
• employment related income. basis.
It helps us understand the things that may affect your rate of
payment, if you are eligible. Australia Go to next question
You can skip this step if: Other Give country below
• you are already on a Centrelink income support payment, and
• there are no changes to your circumstances.

41 Have you ever travelled outside Australia, including short trips

About you and holidays?
This question will help us to verify your Australian residence.
35 Do you need an interpreter?
No Go to next question
Available in international, Indigenous, Auslan and other sign
languages. Yes Give details below
Year you last entered Australia
No Go to 38
Yes Go to next question
Passport number
36 What is your preferred spoken language?
Country of issue

37 What is your preferred written language?

42 Are you an Australian citizen who was born in Australia?
No You need to provide proof of your Australian
residence status (for example, citizenship
38 Read this before answering the following question. papers, passport or other documentation).
This question is voluntary and will not affect your payment. Go to next question
If you do answer, the information will help us to continue
to improve services to Aboriginal and Torres Strait Islander
Yes Go to 50
Australians.
Are you of Aboriginal or Torres Strait Islander Australian
descent? 43 What is your country of birth?
If you are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
44 What is your country of citizenship?
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian Australia Date citizenship granted (DD MM YYYY)

39 Read this before answering the following question. Go to 45

This question is voluntary and will not affect your payment.
If you do answer, the information will help us to continue to Other Give details below
improve services to people of Australian South Sea Islander Country of citizenship
descent.
Australian South Sea Islanders are the descendants of Pacific
Islander labourers brought from the Western Pacific in the Date citizenship granted (DD MM YYYY)
19th Century.
Are you of Australian South Sea Islander descent?
No
Yes

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45 What type of visa did you arrive on? 50 Read this before answering the following question.
Permanent Go to next question We need to know if you have lived in any countries other than
Temporary Go to next question Australia. ‘Lived’ means where you made your home or spent
a long period of time – it does not include places you visited
New Zealand passport Go to 47 for a holiday.
(Special Category visa)
Have you ever lived outside Australia for any period?
Not sure Go to 47
No Go to next question

46 Your visa details on arrival Yes List all countries you have lived in since birth and the
date you started living in each country.
Visa subclass Date visa granted (DD MM YYYY)
Include when you started living in Australia.
Do not include short trips or holidays.

1 Country
47 Has your visa changed since you arrived in Australia?
No Go to next question
Date from (DD MM YYYY)
Yes Most recent visa details
Visa subclass Date visa granted (DD MM YYYY)

2 Country

48 Did you start living in Australia before 1965?

Date from (DD MM YYYY)
No Go to next question
Yes Give details below
Name of the ship or airline on which you arrived 3 Country

Name of the place where you first arrived/disembarked Date from (DD MM YYYY)

What was your name when you first arrived in Australia?

4 Country

49 Did someone provide you with an assurance of support for your Date from (DD MM YYYY)
migration to Australia?
If you want more information on assurance of support, go to www.

servicesaustralia.gov.au/assurance 5 Country
No
Not sure Date from (DD MM YYYY)
Yes

6 Country

Date from (DD MM YYYY)

If you need more space, provide a separate sheet with details.

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 Your partner 56 Do you give permission for your partner to speak to us on your
behalf?
51 Do you have a partner? You can change this authority at any time.
No Go to 74 No
Yes Go to next question Yes

52 Tick one of the boxes below to tell us about your relationship 57 Has your partner been known by any other name(s)?
status right now. Include:
For more information about relationship status, read ‘Having • name at birth • alias
a partner’ on page 2. • name before marriage • adoptive name
If you have ever been separated from your current partner, • previous married name • foster name.
give the date that you most recently got back together • Aboriginal or skin name
(reconciled) with your partner.
This will update your Centrelink record only. If you need to No Go to next question
call us to update your Medicare and/or Child Support record,
go to servicesaustralia.gov.au/phoneus
www.
Yes Give details below
1 Other name
Married Date married or last reconciled
with your partner (DD MM YYYY)

Go to next question Type of name (for example, name at birth)

Registered relationship Date registered or last reconciled

(your relationship with your partner (DD MM YYYY)
is registered under 2 Other name
Australian state or
territory law) Go to next question
De facto Date you started your relationship
(your relationship is or last reconciled with your
Type of name (for example, name before marriage)
similar to a married partner (DD MM YYYY)
couple but you are
not married or in a
registered relationship) Go to next question
If you need more space, provide a separate sheet with details.

53 Your partner’s Customer Reference Number (if known) 58 Your partner’s gender
Male
Female
54 Your partner’s name Non-binary

Mr Mrs Miss Ms Mx Other

59 Do you live in the same home as your partner?
Family name
No Go to next question
Yes Go to 64
First given name

60 Your partner’s permanent address

Second given name

Postcode
55 Your partner’s date of birth (DD MM YYYY)
61 Your partner’s postal address (if different to above)

Postcode

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62 Why are you not living with your partner? 67 Is your partner an Australian citizen who was born in Australia?
Partner’s illness No You will need to provide proof of your
Your illness partner’s Australian residence status
(for example, citizenship papers, passport or
Partner in prison other documentation).
Partner’s employment Go to next question
Other Give details below
Yes Go to 73

68 What is your partner’s country of birth?

63 Period not living with your partner (DD MM YYYY)
From

69 What is your partner’s country of citizenship?

To
Australia Date citizenship granted (DD MM YYYY)
OR indefinite

Go to 71
64 In the last 14 days did your partner get any of the following
payments? Other Give details below
• ABSTUDY • JobSeeker Payment Country of citizenship
• Age Pension • Parenting Payment
• Austudy • Special Benefit
• Carer Payment • Youth Allowance. Date citizenship granted (DD MM YYYY)
• Disability Support Pension

No Go to next question
Yes Go to 78 70 Has your partner ever lived in Australia?
No Go to 78
65 What country is your partner currently living in? Yes Go to next question

This is the country where your partner normally lives on a

long term basis. 71 What type of visa did your partner arrive on?
Permanent Go to next question
Australia Go to next question
Temporary Go to next question
Other Give country below
New Zealand passport Go to 73
(Special Category visa)
Not sure Go to 73
66 Has your partner ever travelled outside Australia, including
short trips and holidays? 72 Your partner’s current visa details
This question will help us to verify your partner’s Australian Visa subclass Date visa granted (DD MM YYYY)
residence.

No Go to next question
Not applicable – never Go to next question
travelled to Australia
Yes Give details below
Year last entered Australia

Passport number

Country of issue

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73 Read this before answering the following question. 74 Tick one of the boxes below to tell us about your relationship
status right now.
We need to know if your partner has lived in any countries
other than Australia. ‘Lived’ means where your partner made For more information about relationship status, read ‘Having
their home or spent a long period of time – it does not include a partner’ on page 2.
places they visited for a holiday. This will update your Centrelink record only. If you need to
Has your partner ever lived outside Australia for any period? call us to update your Medicare and/or Child Support record,
go to servicesaustralia.gov.au/phoneus
www.

No Go to 78
Yes List all countries your partner has lived in since birth Separated Date of last separation
and the date they started living in each country. (previously in a (DD MM YYYY)
Include when your partner started living in Australia. marriage, registered or
Do not include short trips or holidays. de facto relationship)
Go to 76
1 Country
Divorced Date of divorce (DD MM YYYY)

Date from (DD MM YYYY)

Go to 76
Widowed Date of partner’s death
(previously in a (DD MM YYYY)
2 Country marriage, registered or
de facto relationship)
Go to 75
Date from (DD MM YYYY)
Never married or lived Go to 78
with a partner

3 Country
75 Give details about your deceased partner
Full name
Date from (DD MM YYYY)

Date of birth (DD MM YYYY)

4 Country
Go to 78
Date from (DD MM YYYY)
76 Your ex-partner’s family name

5 Country
First given name

Date from (DD MM YYYY)

Second given name

6 Country
77 Your ex-partner’s current address (if known)
Date from (DD MM YYYY)

Postcode
If you need more space, provide a separate sheet with details.
Go to next question
Go to 78

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 Your living arrangements Person 1

78 Do you share your accommodation with anyone other than an D If you participate in activities jointly with this person, are
immediate member of your family? you considered to be a couple?

Immediate family members are parents (including step-parent No

and legal guardian), sibling, step-sibling, child (including Yes
adopted, step child or foster child), grandparent or grandchild.
E Have you and this person previously lived together as a
No Go to 80 couple (for example, married, partnered, de facto or in a
Yes Go to next question registered relationship)?
No Go to F
79 Read this before answering the following question. Yes Both you and your ex-partner each
We need full details about your living arrangements to work need to complete and return a separate
out your correct payment. Relationship details – Separated under
one roof (SS293) form.
The answers to these questions will help us decide if further
supporting documentation is needed from you. If you are If you do not have this form, go to www.

making a claim, you must return any supporting documents servicesaustralia.gov.au/forms

at the same time you lodge your claim form. Go to G

Give details of each person who shares your accommodation. F Did you answer ‘Yes’ at B, C or D, for this person?
Include anyone who: No Go to H
• regularly stays any number of nights per week Yes
• uses your home as a base (for example, truck drivers, Both you and the other person each
miners, flight attendants or members of the armed forces). need to complete and return a separate
Relationship details (SS284) form.
Do not include immediate family members. If you do not have this form, go to www.

servicesaustralia.gov.au/forms
Person 1 Go to G

Full name G Are you concerned about your safety if forms are issued to
this person?
No Go to H
When did you start sharing with this person
Yes If you have been advised to provide a
Age (DD MM YYYY)?
Relationship Details – Separated under one
roof (SS293) form or a Relationship Details
(SS284) form then only you need to complete
the form. You do not need to request your
What is your relationship to this person? ex-partner or the other person to complete
the form.
Go to H
A Have you and this person shared accommodation at another
address? H Is there another person who shares your accommodation?
No No Go to 80
Yes Yes Give details of Person 2

B Do you and this person share the parenting/guardianship of

any children?
No
Yes

C Have you and this person ever had any joint financial
commitments (for example, joint bank account, mortgage
or other loans)?
No
Yes

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 Person 2 Person 2

Full name G Are you concerned about your safety if forms are issued to
this person?
No Go to H
When did you start sharing with this person
Age (DD MM YYYY)? Yes If you have been advised to provide a
Relationship Details – Separated under one
roof (SS293) form or a Relationship Details
(SS284) form then only you need to complete
What is your relationship to this person? the form. You do not need to request your
ex-partner or the other person to complete
the form.
Go to H
A Have you and this person shared accommodation at another
address? H Is there another person who shares your accommodation?
No No Go to next question
Yes Yes Provide a separate sheet with full details
of each additional person.
B Do you and this person share the parenting/guardianship of
any children? Go to next question
No
Yes

C Have you and this person ever had any joint financial
commitments (for example, joint bank account, mortgage
or other loans)?
No
Yes

D If you participate in activities jointly with this person, are

you considered to be a couple?
No
Yes

E Have you and this person previously lived together as a

couple (for example, married, partnered, de facto or in a
registered relationship)?
No Go to F
Yes Both you and your ex-partner each
need to complete and return a separate
Relationship details – Separated under
one roof (SS293) form.
If you do not have this form, go towww.

servicesaustralia.gov.au/forms
Go to G

F Did you answer ‘Yes’ at B, C or D, for this person?

No Go to H
Yes Both you and the other person each
need to complete and return a separate
Relationship details (SS284) form.
If you do not have this form, go towww.

servicesaustralia.gov.au/forms
Go to G

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 About your home 83 What type of accommodation best describes where you
(and your partner) live?
80 Do you (and/or your partner) own a home that you do not live in? You are single, 18 to 20 years old and living
No Go to 82 in the principal home of a parent Go to 113

Yes Go to next question In a place where you (and/or your partner)

pay private rent – this includes when you
live in a caravan park and pay site fees or
81 What is the reason you (and/or your partner) do not live in the live on a vessel and pay mooring fees Go to 105
home? In a home you (and/or your partner) own or
You or your children are studying you own jointly with another person –
Getting medical treatment this can include:
• paying it off (mortgage)
Getting care from a person in a • a caravan, mobile home or boat Go to 84
private home
In a home owned by:
Getting care in a nursing home
• a company in which you (and/or your
Providing care to a person in a partner) are a shareholder or director, or
private home
• a trust in which you (and/or your partner)
Overseas absence or a member of your family are a
Other Give details below potential beneficiary or are named in the
trust deed Go to 113
In public housing, for example, housing
owned by the Housing Authority. This does
not include paying rent to a Community
Housing organisation. Go to 85
82 Have you (and/or your partner) sold your former home within In a boarding house, guest house, hostel,
the last 24 months and intend to buy or build a new family hotel, campus, refuge, emergency or
home? supported accommodation or similar Go to 106
No Go to 83 In a hospital or home for people with
disabilities Go to 106
Yes Give details below
In an aged care home or nursing home Go to 88
What was the date of settlement?
In a retirement village Go to 95
(DD MM YYYY)
In accommodation which you (and/or your
partner) have the right to use for life Go to 99
What was the amount you got after any mortgage and costs
were taken out of the sale price? In accommodation where you pay no rent Go to 113
Other, for example, this could be where you
$
(and/or your partner) do not have a fixed
Give details
address
Provide documents to verify the details of the sale below
(for example, settlement statement). Copies are
acceptable.

What is the total amount you (and/or your partner) intend to

use to buy or build your new family home (cannot exceed the Go to 105
amount of the sale proceeds)?
$
84 Do you pay site or mooring fees for your (and your partner’s)
home (this could be for a caravan, mobile home or boat)?
If you are a member of a couple, what share of the intended
amount do you and your partner each have invested? No Go to 113
You Your partner Yes Go to 105
$ $
85 Is your (or your partner’s) name on the rental contract or lease
Expected date of purchase or completion of your new family agreement?
home
No Go to next question
(DD MM YYYY)
Yes Go to 113

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86 Is the primary tenant paying the market rate of rent? 92 Read this before answering the following question.
No Go to next question Payments for accommodation may include:
Not sure Go to next question • Accommodation Bond
Yes Go to 105 • Accommodation Charge
• Refundable Accommodation Deposit (RAD)
• Daily Accommodation Payment (DAP)
87 Do you (and your partner) live with the primary tenant and your • Daily Accommodation Contribution (DAC)
(and/or your partner’s) income has been taken into account by • Refundable Accommodation Contribution (RAC).
the public housing authority when calculating the rent?
No Go to 113 Did you (and/or your partner) pay, or agree to pay, a daily
payment or a lump sum (either by instalments or in full) for
Yes Go to 105
your accommodation to the Aged Care Provider?

This payment may have been a donation, a loan or some

Aged care home or nursing home type of payment which may be repayable to you in whole or
in part, if you leave. This payment does not include gifts or
88 What is the name of the aged care home or nursing home? loans above the amount you had to pay for the right to your
accommodation.

No Go to 113
Yes Amount of payment

89 What date did you (and/or your partner) move in? $

You
Provide a copy of the signed accommodation
(DD MM YYYY) agreement(s).

Your partner
(DD MM YYYY) 93 Did you (and/or your partner) make a gift and/or loan in addition
for the right to your accommodation?
No Go to 113
90 How long will you (and/or your partner) be staying?
Yes Go to next question
Long term or indefinitely
You Your partner Go to 92 94 What was the additional amount paid as a gift and/or loan?
Short term or temporary respite care Amount of gift
You Your partner Go to next question $
Amount of loan
91 What date do you (and/or your partner) expect to leave?
$
You
(DD MM YYYY) Go to 113

Your partner
Retirement village
(DD MM YYYY)
95 What date did you (and/or your partner) move into the
Go to 113 retirement village?
You
(DD MM YYYY)

Your partner
(DD MM YYYY)

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96 Did you (and/or your partner) pay an entry contribution? 101 Who was transferred the money or assets in return for the right
to accommodation for life?
Your entry contribution may have been a donation, a loan or
some type of payment that may be repayable to you in whole Full name (of the person or organisation)
or in part, if you leave. An entry contribution does not include
gifts or loans above the amount you had to pay for the right
to your accommodation. Address

No Go to next question
Yes Amount of entry contribution

$ Postcode

Provide a copy of the signed contract or

agreement. 102 What was the amount paid?
$
97 Did you (and/or your partner) make a gift and/or loan instead of
or in addition to an entry contribution? 103 What (if any) assets were transferred?
No Go to 105
Yes Go to next question

98 What was the gift and/or loan amount paid?

Amount of gift
$ 104 What was the market value of transferred assets?
Amount of loan $
$

Go to 105
Living with other people

Life interest 105 Read this before answering the following question.
Sharing your accommodation means that you have the right
99 Did you (and/or your partner) pay any money or transfer any to use a kitchen, bedroom or bathroom with one or more
assets in return for this right to accommodation for life? persons. This includes all family members (except your
partner and dependent children), people who regularly stay
No Go to next question at your accommodation and people who work away from
Yes Go to 101 home, for example, truck drivers, miners, flight attendants or
members of the armed forces.
100 Which option describes how you (and/or your partner) obtained Do you (and your partner) share your accommodation with
a life interest in a home without any exchange of money or other people?
transfer of assets?
No Go to next question
Inherited the life interest Go to 113
Yes Give details below
A formal agreement documenting Go to 113
the life interest 1 Person’s name
An informal agreement, no rent paid Go to 113
An informal agreement to live at a Go to 105 Age Date they moved in (DD MM YYYY)
child’s home and pay rent
Other Give details below
Relationship to you Do they own the home?
No Yes
Their share of the rent/lodgings
Go to 105 (not required if they own the home)
$ per

SA466.2404
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 Continued Paying for accommodation
2 Person’s name
106 Do you (and your partner) pay board and/or lodgings?
Board means you (and your partner) are provided with some
Age Date they moved in (DD MM YYYY) regular meals.
Lodgings means the amount you (and your partner) pay for
your accommodation.
Relationship to you Do they own the home?
No Go to 108
No Yes
Yes Go to next question
Their share of the rent/lodgings
(not required if they own the home)
107 Can you separate the amounts you (and your partner) pay for
$ per
board and/or lodgings?
No Total board and lodgings charged per
3 Person’s name day, week, fortnight, 4 weeks or calendar month
$ per
Age Date they moved in (DD MM YYYY)
Go to 109

Yes Amount paid for board (meals) per

Relationship to you Do they own the home?
day, week, fortnight, 4 weeks or calendar month
No Yes
$ per
Their share of the rent/lodgings
(not required if they own the home) Amount paid for lodgings (accommodation only) per
day, week, fortnight, 4 weeks or calendar month
$ per
$ per
4 Person’s name Go to 109

Age Date they moved in (DD MM YYYY) 108 What is the amount you (and your partner) pay per day, week,
fortnight, 4 weeks or calendar month (for example, rent,
maintenance or site fees)?
Relationship to you Do they own the home?
This would be the total you (and your partner) pay for the
No Yes property minus any subsidy/rebate, rent amount claimed as
a business expense for taxation purposes OR contribution
Their share of the rent/lodgings from another person or organisation.
(not required if they own the home)
$ per $ per

If you need more space, provide a separate sheet with details.

109 On what date did you (and your partner) start paying these
fees?
(DD MM YYYY)

110 What type of accommodation do you (and your partner) live in?
Boarding house/hostel/private hotel, Go to 112
hospital or disability housing
Private house or townhouse/unit/flat
Community housing
Defence housing Go to next question
Caravan/cabin/mobile home
Boat
Other Give details below

Go to next question

SA466.2404
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111 What is the total amount being charged per day, week, fortnight, 114 In the last 12 months, did you (and/or your partner) get
4 weeks or calendar month? or expect to get, any leave entitlement payments from an
employer?
$ per
Include:
• annual leave
112 Do you (and/or your partner) have a formal lease or tenancy • maternity leave
agreement? • long service leave or sick leave you got when you stopped
work
No Go to next question • entitlements that you cashed in before you stopped work
Yes Provide a full copy of your signed lease or • money in a long-service leave fund or scheme that you
tenancy agreement. have not cashed in.

No Go to next question
Yes Give details below
Employment related income
Provide documents which confirm each
leave entitlement payment (for example,
113 In the last 12 months, have you (and/or your partner) stopped Employment Separation Certificate (SU001)
working for any employers (including self-employment)? form or letter from the employer).
No Go to next question If you do not have this form, go to
www.

Yes Give details below servicesaustralia.gov.au/forms

Provide documents which confirm: 1 Type of leave entitlement payment

• that you (and/or your partner) stopped
work (for example, Employment
Separation Certificate (SU001) form or Amount (before tax and Number of working days
letter from the employer), or other deductions) covered by the payment
• your (and/or your partner’s) business has
stopped trading. $
If you do not have this form, go to www.
Date paid or date payable (DD MM YYYY)
servicesaustralia.gov.au/forms

1 Employer or business name Leave entitlement for

You Your partner

Australian Business Number (ABN) Employer’s details

Name of business

Who works for this employer? Australian Business Number (ABN)

You Your partner

Phone number (including area code)

2 Employer or business name

Australian Business Number (ABN)

Who works for this employer?

You Your partner

If you need more space, provide a separate sheet with details.

SA466.2404
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 Continued Tax file number(s)
2 Type of leave entitlement payment
116 Read this before answering the following questions.
You are not breaking the law if you do not give us your (and
Amount (before tax and Number of working days your partner’s) tax file number(s) (TFN), but if you (and your
other deductions) covered by the payment partner) do not provide them to us, or authorise us to get
$ them from the Australian Taxation Office, you may not be paid.
In giving us your (and your partner’s) TFN in relation to this
Date paid or date payable (DD MM YYYY) claim you authorise us to use your (and your partner’s) TFN
for other social security payments and services in future
where necessary.
Leave entitlement for Have you (and your partner) given us your tax file number(s) before?
You Your partner No Go to next question
Employer’s details Not sure Go to next question
Name of business Yes Go to 118

117 Do you (and your partner) have a tax file number(s)?

Australian Business Number (ABN)
You
No Go to ato.gov.au
www.

Phone number (including area code) Yes Your tax file number

If you need more space, provide a separate sheet with details. Your partner
No Go to ato.gov.au
www.

115 Did you (and/or your partner) get a redundancy payment in the last Yes Your partner’s tax file number
2 years?
No Go to next question
Yes Provide documents which confirm any
redundancy payments (for example,
118 Are you younger than 21 years?
Employment Separation Certificate (SU001) No Go to Step 5 – your checklist and declaration
form or letter from the employer). on page 26
If you do not have this form, go to
www.

Yes Go to Step 4 – your independence on page 24

servicesaustralia.gov.au/forms

SA466.2404
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 Step 4 – your independence

You must complete this step if you are younger than 21 years. 121 Tick all of the following circumstances which apply to you. If you
It helps us decide your rate of payment if you are eligible. tick more than one you only need to provide evidence for one.
You have worked on average 30 hours per week for
119 Read this before answering the following questions. 18 months in a 2 year period

You may get Telephone Allowance if you have a telephone Provide proof of hours and periods worked,
connected in your home. You can also get it if the connection for example, payslips or letter from your
is in your partner’s name. employer.
You must be younger than 21 years with no dependent
You have earned 75% or more of Wage Level A of the
children to get Telephone Allowance.
National Training Wage Schedule:
• since leaving secondary school, and
Whose name is the home phone account in?
• within an 18 month period.
My name
My partner’s name For more information, go to guides.dss.gov.au and
http://

search for National Training Wage Schedule.

Another name
Not applicable Provide proof of income earned and periods
worked, for example, payslips, letter from your
Whose name is the mobile phone account in? employer or payment summaries.
My name
Since leaving secondary school, you have worked at least
My partner’s name 15 hours per week for 2 years
Another name
Provide proof of employment, for example,
Not applicable payslips, letter from the employer.
If you (and/or your partner) have a home internet connection, You are, or have been, married or in a registered
what is the name of your Internet Service Provider (ISP)? relationship
The ISP is the company that provides your internet access.
Provide proof of marriage or relationship
registration.
Whose name is the ISP account in? You currently have a dependent child in your care
My name
Provide proof of birth for this child, if you have
My partner’s name not already done so.
Another name
You have previously had a dependent child in your care
Not applicable
Provide proof of birth for this child, if you have
not already done so.
120 Are you still attending secondary school?
No When did you leave? You lived, or are living, as a member of a couple in a
relationship that has lasted:
(DD MM YYYY) • for at least 12 months, or
• for at least 6 months where the relationship ended
Yes Go to next question
due to exceptional circumstances, such as domestic
violence or death of a partner
You are an orphan
You may need to provide evidence.

You are a refugee living in Australia without your parent(s)

Your parent(s) are not able to exercise their parental
responsibilities because:
• they are in a nursing home
• they are mentally incapacitated
• they cannot be located, or
• they are in prison
You are, or have been, in state care
None of the above

SA466.2404
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122 Do you live with your parent(s)?
No Go to next question
Yes Go to Step 5 – your checklist and declaration
on page 26

123 Are you younger than 18 years?

No Go to Step 5 – your checklist and declaration
on page 26
Yes Go to next question

124 Do you live away from your parents’ home because of a

disability, illness or injury?
No Go to next question
Yes Give details below

Go to Step 5 – your checklist and declaration on page 26

125 Is it unreasonable for you to live at home with your parent(s)?

No Go to Step 5 – your checklist and declaration
on page 26

Yes You need to call us on 132 717 to make an

appointment with a social worker.
Go to Step 5 – your checklist and declaration on
page 26

SA466.2404
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 Step 5 – your checklist and declaration

Continued
You must complete this step. It helps you to identify the information
to give us with your claim. It also includes your declaration. A copy of the signed accommodation agreement(s)
(if you answered Yes at question 92)
A copy of the signed contract or agreement
Your checklist (if you answered Yes at question 96)
Signed lease or tenancy agreement
126 Which of the following forms and/or documents are you (and/or (if you answered Yes at question 112)
your partner) providing with this form? Employment Separation Certificate (SU001) form or
If you are not sure, check the question to see if you should documents that confirm that you (and/or your partner)
provide the documents. stopped work or your (and/or your partner’s) business has
stopped trading
Original identity documents (if you answered Yes at question 113)
For a full list of acceptable documents, go to
www.

Employment Separation Certificate (SU001) form or

servicesaustralia.gov.au/identity documents that confirm each leave entitlement payment
Authorising a person or organisation (if you answered Yes at question 114)
to enquire or act on your behalf (SS313) form
Employment Separation Certificate (SU001) form or
(if you answered Yes at question 9) documents that confirm each redundancy payment
Income and assets (SA369) form (if you answered Yes at question 115)
(if you answered Yes at question 24, Proof of employment
if you answered No at question 33)
(if required at question 121)
Letter or document that gives the reference number
Proof of marriage or relationship registration
and details of each New Zealand payment
(if required at question 121)
(if you answered Yes at question 25)
Dependent children proof of birth
Letter or document that gives the reference number and
details of each Department of Veterans’ Affairs payment (if required at question 121)
(if you answered Yes at question 26)
Letter or document(s) that gives the reference number
and details of each Self-Employment Assistance
payment
(if you answered Yes at question 27)
Compensation and damages (Mod C) form
(if you answered No at question 29)
A copy of the policy document and the latest statement
for this policy
(if you answered Yes at question 30)
Proof of Australian residence status
(if you answered No at questions 42 or 67)
Relationship details – Separated under one roof
(SS293) form
(Both you and your ex-partner (for each Person 1 and/
or Person 2), if you answered Yes at question 79 E and
No at question 79 G
or
only you, if you answered Yes at question 79 E and
Yes at question 79 G)
Relationship details (SS284) form
(Both you and the other person (for each Person 1 and/
or Person 2), if you answered Yes at question 79 F and
No at question 79 G
or
only you, if you answered Yes at question 79 F and
Yes at question 79 G)
Details of each additional person who shares your
accommodation
(if you answered Yes at question 79 H)
A copy of documents to verify the details of the sale
(if you answered Yes at question 82)

SA466.2404
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 Privacy notice

127 You (and your partner) need to read this

Privacy and your personal information
The privacy and security of your personal information
is important to us, and is protected by law. We collect
this information so we can process and manage your
applications and payments, and provide services to you.
We only share your information with other parties where you
have agreed, or where the law allows or requires it. For more
information, go to servicesaustralia.gov.au/privacypolicy
www.

Declaration

128 I declare that:

• the information I have provided in this form is complete and
correct.
I understand that:
• I must notify Services Australia of any changes to this
information within 14 days of the change(s) occurring.
• Services Australia can make relevant enquiries to make
sure I get the correct entitlement.
• giving false or misleading information is a serious offence.

Your signature

On completion of this form,

print and sign by hand

Date (DD MM YYYY)

Your partner’s signature (if applicable)

On completion of this form,

print and sign by hand

Date (DD MM YYYY)

SA466.2404
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Read the following when you are ready to return your
completed claim.
When returning your completed claim:
• if you are returning this form in person at a service centre
or by post
- make sure you include this page.
• if you are uploading this form through your Centrelink
online account, or Express Plus Centrelink mobile app
- make sure you upload pages 29 to 34 using the
form code MEDSA466.

This will help us assess your claim more quickly.

For more information, go towww.

servicesaustralia.gov.au/centrelinkuploaddocs

Go to the next page to continue your claim.

 Step 6 – your medical details

You must complete this step. This step is about: 131 Select one option that best describes your condition.
• your disability or medical condition(s) Are you claiming because you:
• your treatment
• your treating health professional(s)
A Are permanently blind
We need these details to help assess your medical eligibility for This means you have:
DSP. • visual acuity on the Snellen Scale after correction
by suitable lenses of less than 6/60 in both eyes,
or
• constriction to within 10 degrees of fixation in the
129 Read this before answering the following questions. better eye irrespective of corrected visual acuity, or
To get DSP your condition(s) must: • a combination of visual defects resulting in the
• be diagnosed by a qualified medical professional, and same degree of visual loss as that occurring in the
• likely persist for more than 2 years, and above points.
• stop you working in any job for at least 15 hours a week
in the next 2 years. You need to provide a Request for
For more information, go to Ophthalmologist/Optometrist Report (SA013)
form or equivalent information from your treating
www.

servicesaustralia.gov.au/dspmedicalrules
ophthalmologist. If you do not have this form, go
List any conditions that affect your ability to work. Start with to servicesaustralia.gov.au
www.

the one you think has the most impact. Go to 138

B Need nursing home level care or palliative care

This means you:
• are a long term patient of a hospital or nursing
home, or
• are in your own home and need the same care as
in a nursing home due to your disability or medical
condition(s).

You need to provide medical evidence that

confirms your symptoms and prognosis.
Evidence may include Occupational Therapy
Reports or specialist reports, hospital discharge
summaries.
Go to 138

C Have a terminal illness with a life expectancy of less

than 2 years
Your evidence needs to show:
• your life expectancy is 2 years or less due to
your disability or medical condition, or
• the average life expectancy for someone with
the same condition is less than 2 years.
Go to 133

130 When did your condition(s) begin to significantly affect your

ability to work?
If you cannot provide an exact date, try to be as accurate as
you can.

(DD MM YYYY) CLK0MEDSA466 2404

MEDSA466.2404
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 Continued 132 For some conditions, we need specialist medical evidence.
Select the options that best describe your condition(s).
Are you claiming because you:
Tick all that apply
D Have an intellectual disability with an assessed IQ of
less than 70 Are you claiming because of:

Your evidence needs to show: A An eye condition affecting your vision, but you are not
• your treating health professional says you permanently blind
have an intellectual disability, and You need to give us evidence that an
• a psychologist has assessed your IQ as less ophthalmologist or ophthalmic surgeon supports
than 70, or your treating doctor’s diagnosis.
• a psychologist has confirmed you are unable Your evidence could include information about
to undergo testing. your:
Go to 134 • ability to read print or road signs, or
• need to use visual aids.
E Have category 4 HIV/AIDS Your evidence could be a Request for
Ophthalmologist/Optometrist Report (SA013)
You need to give us details from your treating form or equivalent.
doctor that shows your diagnosis, stage of If you do not have this form, go to
treatment and prognosis.
www.

servicesaustralia.gov.au
Go to 133
B A mental health condition
F Get a Disability Compensation Payment at the Special
Rate (TPI) from the Department of Veterans’ Affairs (DVA) You need to give us evidence a psychiatrist
DVA reference number diagnosed your condition, or evidence a
registered psychologist supports your treating
doctor’s diagnosis.
This could include information about your ability
You need to give us the Special Rate decision to:
letter from the DVA. • live independently and interact with people,
If you do not have your letter, we may be able to or
confirm the details with the DVA for you. • plan, concentrate and make decisions.
Go to 141
C An ear condition affecting your hearing or balance
G None of the above You need to give us evidence an audiologist or
an ear, nose and throat specialist supports your
treating doctor’s diagnosis.
Your evidence could include information about
your:
• ability to hear sounds in different settings, or
• need to use assistive listening devices or sign
language, or
• difficulty with balance.

D An intellectual disability with an assessed IQ of 70 or

more

You need to give us specific medical evidence

for this condition. This will help us assess your
intellectual disability.
Your evidence should include an assessment of
intellectual function and adaptive behaviour by a
psychologist.

E A disability or medical condition not listed above

MEDSA466.2404
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133 Read this before answering the following question. Continued
Provide details of current treatment
To get DSP, your condition(s) needs to be reasonably treated.
If you are not getting any treatment, write “none”.
To assess if your condition is reasonably treated, we
check what treatment you have had. This is treatment from
your doctor or health professional. We check your current
treatment and if any further treatment is planned for you.
We consider the next 2 years from when you claim.
We look at your medical evidence to assess:
• the suitability of the treatment
• the outcomes of the treatment
• if further treatment may help
• if there are medical or other reasons why you cannot get
treatment.
Your condition also needs to be stabilised.
To check if your condition is stabilised, we look at your
medical evidence. We consider the next 2 years from when
you claim.
A condition is stabilised when, even with reasonable
treatment:
• the condition will not significantly improve
• you will not be able to work at least 15 hours per week in
the next 2 years.
To determine if your condition(s) is reasonably treated and
stabilised we need to know your:
• current treatment details
• past treatment details
• future treatment details.
If the questions about treatment are not relevant for your
condition(s), you can say in the space provided. For example,
there is no treatment for your condition(s).
Provide details of future treatment you are expecting
You need to provide medical evidence to support your
statements about your treatment. If you will not get any treatment in the future, write “none”.

Provide details of past treatment

If you have not had any treatment, write “none”.

If you need more space, provide a separate sheet with details.

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134 Have you been to a special school or Special Education Unit 136 Did you, or do you, get any of the following extra support in the
because of your condition(s)? workplace because of your condition(s)?
Even if this was many years ago this information can help us This is support that you have had or you are getting now, not
assess your claim. what you think you should get.

No Go to next question Tick all that apply

Yes Give details below Modification to your work environment
Name of school Reduced hours of work
Alternative duties
Address
Retraining
On the job support
No, I did not/do not get any extra support in my workplace
Postcode

137 Read this before answering the following questions.

135 What sort of work have you done in the last 12 months? A Program of Support is a Government funded program that
If you have not worked in the last 12 months, write ‘none.’ helps people to prepare for, find and keep a job.
1 Type of work To get DSP you may need to have participated in a
Program of Support within the last 3 years. This can
include participating with Disability Employment Services,
Did your condition(s) affect your ability to do this work? Community Development Program, or Workforce Australia.
For more information about Program of Support, go to
No
www.

servicesaustralia.gov.au/dspprogramofsupport
Yes Give details below
In the last 3 years, have you done any programs to help you:
• find work
• stay in a job
• return to work
• manage an injury
• get vocational rehabilitation
• gain new skills, work experience or training?
No Go to next question
2 Type of work
Yes Give details below

1 Name of provider
Did your condition(s) affect your ability to do this work?
No
Yes Give details below Dates you participated (DD MM YYYY)
From

To

2 Name of provider

Dates you participated (DD MM YYYY)

From

To

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138 List the treating health professional(s) we can contact if 139 Read this before answering the following questions.
we need to talk to them about your medical evidence and
condition(s). It may help us make a quicker decision about We need current medical evidence, from your treating health
professional(s), about the condition(s) that affect your ability
your claim.
to work.
It is OK to list only one. The evidence should tell us:
You still need to provide medical evidence. • your diagnosed condition(s)
• when the medical condition(s) was diagnosed
1 Full name
• current symptoms of your condition(s)
• past, current and planned treatment
Profession • how your condition(s) affect you day to day
• the name, qualification and contact details of your
treating health professional(s).
Address If the information is more than 2 years old, check with your
treating health professional, as it may not be current.
We do not get the evidence for you.
Statements from you or your nominee are not considered
medical evidence.
Postcode
We do not accept material that is abusive, offensive or
Phone number (including area code) contains illegal content.
You do not need to provide everything on the list below.
For more information, go to www.

servicesaustralia.gov.au/dspmedicalevidence
2 Full name
What medical evidence documents are you providing with your
Profession claim?
Tick all that apply
Medical history records, such as a patient health summary
Address signed by your GP
Report from a medical specialist, such as an ear, nose and
throat specialist, psychiatrist or ophthalmologist
GP referral letter to medical specialist
Postcode
Report from another treating health professional, such as
Phone number (including area code) a physiotherapist, psychologist, occupational therapist,
audiologist or optometrist
Rehabilitation reports
3 Full name
Medical imaging report, such as MRI, X-ray, CT
(films not required)
Profession Hospital/Outpatient/Discharge report
Compensation medical report
Address
Wait-list confirmation letter
Special School/Special Education Unit report
Other medical evidence – give details below
Postcode
Phone number (including area code)

If you have more than 3 professionals to list, provide a

separate sheet with details.

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140 Are you having difficulty giving us evidence? Privacy notice
No Go to next question
Yes To help us understand, tell us why you are having 141 You need to read this
difficulty with medical evidence. Privacy and your personal information
The privacy and security of your personal information
is important to us, and is protected by law. We collect
this information so we can process and manage your
applications and payments, and provide services to you.
We only share your information with other parties where you
have agreed, or where the law allows or requires it. For more
information, go to servicesaustralia.gov.au/privacypolicy
www.

Declaration

142 I declare that:

• the information I have provided in this form is complete and
correct.
I understand that:
• I must notify Services Australia of any changes to this
information within 14 days of the change(s) occurring.
• Services Australia can make relevant enquiries to make sure
I get the correct entitlement.
• giving false or misleading information is a serious offence.

Your signature

On completion of this form,

print and sign by hand

Date (DD MM YYYY)

Important information
Before returning your claim form and documents, you can
complete Step 7 – Consent to disclose medical information
– this may help us to assess your claim more quickly.

Clear

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Read the following when you are ready to return your
completed claim.
When returning your completed claim:
• if you are returning this form in person at a service centre
or by post
- make sure you include this page.
• if you are uploading this form through your Centrelink
online account, or Express Plus Centrelink mobile app
- make sure you upload the next page using the form
code SA472.

This will help us assess your claim more quickly.

For more information, go towww.

servicesaustralia.gov.au/centrelinkuploaddocs

Go to the next page to continue your claim.

 Instructions Clear

Consent to disclose medical information

(SA472)

Step 7 – consent to disclose medical information

Purpose of this form You need to read this
This form is used to confirm that you consent to your treating health Privacy and your personal information
professionals and/or health providers disclosing relevant information The privacy and security of your personal information is important
about your disability or medical conditions to Services Australia, or to us, and is protected by law. We collect this information so we
assessors engaged by Centrelink. can process and manage your applications and payments, and
This consent form does not replace the need for you to provide provide services to you. We only share your information with
medical evidence when lodging a claim for Disability Support other parties where you have agreed, or where the law allows or
Pension (DSP). We need medical evidence from your treating health requires it. For more information, go to www.

professionals to help us understand how your condition affects servicesaustralia.gov.au/privacypolicy

you and to correctly assess your claim. This is explained in the
Medical Evidence Checklist (SA473) form and the Claim for
Disability Support Pension (SA466) form available on our website.
If more information is needed to assess your eligibility for DSP or Consent to disclose medical information
employment services, Centrelink, or assessors engaged by us may I (full name)
contact your treating health professionals and/or health providers
to confirm or clarify information you provide about your disability or
medical conditions. Date of birth (DD MM YYYY)
This may include contact with any health professionals (including
your treating doctor) and/or health providers who have examined,
diagnosed or treated your disability or medical conditions which are of (address)
relevant to your eligibility for DSP or employment services.
Your treating health professionals and/or health providers may be
asked to disclose any medical information relevant to assessing your
eligibility for DSP or employment services. This includes medical Postcode
and specialist reports, clinical notes, medical records or other
information, and any barriers that may affect your ability to work or give consent for my treating health professionals and/or health
participate in employment services or other assistance programmes. providers to disclose any relevant information about my disability
or medical conditions to Centrelink, or assessors engaged by
Your treating health professionals and/or health providers may ask
Centrelink, if required to assess my eligibility for Disability Support
for confirmation that you have consented for them to disclose your
Pension or employment services.
medical information to Centrelink or assessors engaged by us.
You can complete the Consent to disclose medical information Your signature
statement on this form to provide your consent, and Centrelink
will show this to your treating health professionals and/or health On completion of this form,
providers if requested. print and sign by hand
You can withdraw your consent at any time by advising Centrelink.
However, if your treating health professionals or health providers Date (DD MM YYYY)
do not disclose relevant medical information when requested,
Centrelink may not have enough information to assess your eligibility
for DSP or employment services. This may result in your claim being
rejected or your payment being stopped.

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