SU415: Centrelink Medical Certificate Form

Enter the patient's CRN, Family name, First name, Second name, Date of birth (DD MM YYYY), Home address and Postcode.

Enter the Specific diagnosis, a mandatory question (marked *). List your patient's diagnosed medical condition(s) that has a functional impact on their ability to do any work, study or participate in activities. Provide a specific clinical diagnosis, if available, including staging and/or disease classification. For example, "cervical spondylosis" rather than "neck pain", and "major depressive disorder" or "adjustment disorder with depressed mood" rather than "depression".

Enter the Date of onset (if known) (DD MM YYYY).

Indicate the expected duration of the current functional impact of the medical condition (including a temporary exacerbation of a permanent condition), a mandatory question (marked *).

Select up to 13 weeks if the current functional impact is expected to fully resolve within 13 weeks.

Select more than 13 weeks and up to 24 months if the current functional impact is expected to persist for more than 13 weeks and fully resolve within 24 months. Your patient may be receiving treatment or rehabilitation for cancer/leukemia, severe stroke, acquired brain injuries, serious burns, and serious physical injuries. This could include a severe mental health condition for which the person is receiving treatment in an institutional setting.

Select more than 24 months if the current functional impact is expected to persist beyond 24 months and not likely to improve with treatment.

Mark No or Yes for: Will this result in an average life expectancy of 24 months or less?

Mark No or Yes for: Does this condition meet one of the serious illness categories outlined on page 2 of the Notes?

A serious illness exemption may be granted for some payments. A serious illness can include cancer/leukemia, severe stroke, acquired brain injury, severe burns, severe physical injury requiring long recovery period, severe mental health conditions with treatment in an institutional setting.

For the Secondary condition, enter the Specific diagnosis and the Date of onset (if known) (DD MM YYYY), and mark the duration of the current functional impact of this condition as up to 13 weeks, more than 13 weeks and up to 24 months, or more than 24 months.

Detail the day-to-day functional impact the listed medical condition(s) has on the patient, including how it affects their ability to work, study or participate in activities. Functional impact can include how well they can sit or stand, interact with other people, concentrate, use their senses and undertake self-care (for example, showering, dressing, grooming tasks).

Include any assistance or interventions that may help your patient to find and keep a job (for example, a rehabilitation or pain management program).

Detail past, current and future/planned treatment for the listed medical condition(s). This includes symptom management and functional rehabilitation treatment, as well as curative treatment.

Mark No or Yes for: Is there any other condition(s) impacting capacity to work, study or participate in activities? For Yes, you need to complete and return a separate Medical certificate (SU415) form.

If your patient has more than two conditions that have a functional impact, you will need to provide the details on a separate medical certificate.

Enter From and To (DD MM YYYY) for how long this incapacity is expected to last, a mandatory question (marked *). A medical certificate for a temporary incapacity should only be provided for the period medically required.

Mark No or Yes for: Can this patient do any work, study or participate in activities of 8 hours or more per week? Enter how many hours they can work, study or participate in activities on average each week.

A temporary exemption from Centrelink mutual obligation, participation or study requirements may be granted by Services Australia for the period where a patient's capacity to work, study or participate in activities is less than 8 hours per week.

Where a patient has a medical condition that reduces their capacity to work, study or participate in activities of 8 hours or more per week, a Services Australia allied health professional may conduct an assessment to determine the most appropriate support program or align activities to the patient's capacity.

Capacity to work includes any work that a person is capable of doing, not just work the person has previously done, prefers or what they are qualified for. Capacity is not determined by non-medical factors (for example, age, work experience, education or language barriers).

Enter the Doctor's name (type or print in BLOCK LETTERS), Qualification(s), Provider no., Surgery/Medical centre/Hospital name, Address, Postcode and Phone number (including area code).

On completion of this form, print and sign by hand at Signature, and enter the Date (DD MM YYYY).

Return this form and any supporting documents to your patient to lodge with Services Australia or upload using their Centrelink online account through myGov.

There are penalties for offences against section 202 of the Social Security (Administration) Act 1999, the section under which the personal information provided by your patient must be kept confidential.

If you are an eligible medical practitioner, you can complete and lodge a Medical certificate (SU683) form online using Health Professional Online Services (HPOS). If you use HPOS, you do not need to complete this Medical certificate (SU415) form.