Medical Report For Assessor Form centerlink PDF Details

The Medical Report for Assessor form plays a pivotal role in the lives of individuals seeking income support or entry into specific government-supported programs, such as rehabilitation or training, and the Supported Wage System in Australia. It requires detailed completion by a treating doctor or specialist, focusing on the applicant's medical condition and its impact on their functionality and eligibility for support. The form includes the customer's personal details, while delineating clear instructions for both the customer and the doctor involved in the process. For the customer, it outlines steps to ensure their details are filled in, scheduling and attending an appointment with their doctor, and returning the completed form. The doctor's section solicits comprehensive medical information, treatment history, and an assessment of the patient’s condition. Notably, this form not only facilitates a thorough review by the Department of Human Services but also underscores the importance of privacy and consent in handling and disclosing personal and medical information. By ensuring meticulous completion and submission, this form serves as a crucial link between individuals with medical conditions and the support systems designed to assist them, reflecting a process grounded in attention to detail, privacy considerations, and a commitment to capturing the nuances of each individual's health status.

QuestionAnswer
Form Name Medical Report For Assessor Form centerlink
Form Length 11 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 2 min 45 sec
Other names su415 form, centrelink su684, su415, medical certificate su415

Form Preview Example

Medical Report

for Assessor

Customer’s details

Full name

Address

Date of birth

Home phone number

Email address

Postcode

/

/

Centrelink Reference Number (CRN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mobile phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

@

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To be completed by the Assessor issuing the Medical Report

Full name

Organisation

Date

/ /

Information for the customer and the doctor

This Medical Report has been issued by an Assessor so that they can gather additional medical information.

The Medical Report must be fully completed by a treating doctor or specialist. This information will help the Australian Government Department of Human Services in determining:

•income support eligibility

•if the customer may benefit from a program of support, for example rehabilitation or training

•if the customer is eligible to enter the Supported Wage System.

Instructions for the customer

Please use these instructions in order to return the completed Medical Report form.

1Make sure your details are completed (above).

2Contact your doctor and make an appointment to have the Medical Report completed.

Make sure the doctor and their receptionist know that you will need this report completed, as a long consultation may be required. If your doctor does not Bulk Bill, your consultation fee may be more than usual because of the extra time taken to complete the report.

3Attend the appointment with your doctor.

4When your doctor has completed the Medical Report, it must be returned to us.

If you have any questions about this report, call us on 132 717.

Continued

Information for the doctor

Completing this report

In this report you will be asked to provide information about your patient’s medical condition(s). Please complete all the required questions in this report.

If you require another copy of the Medical Report, go to our website humanservices.gov.au/medicalreport

If you need more information in order to complete the Medical Report call us on 132 150.

Returning this report to Human Services

You can give this report and any attachments to your patient or you can return this report directly to us. When returning the form to us, please use the address provided on page 9 of this form.

Continued

CLK0SA433 1207

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Instructions for the customer – continued

Important – This request is a notice given under section 63 of the

Social Security (Administration) Act 1999.

IMPORTANT INFORMATION

Privacy and your personal information

Centrelink, Medicare Australia, Child Support and CRS Australia are services within the Australian Government Department of Human Services (Human Services).

Your personal information is protected by law, including the Privacy Act 1988. Your information is collected for Social Security, Family Assistance, Medicare, Child Support and CRS purposes. This information may be required by the powers provided within each services’ legislation or voluntarily given by you when you apply for services or payments.

Your information will be used for the assessment and administration of payments and services. Your information may also be used within Human Services, where you have provided consent or it is required or authorised by law. Human Services may disclose your information to Commonwealth departments, other persons, bodies or agencies ONLY where you have provided consent or it is required or authorised by law.

You can get more information about privacy by going to our website www.humanservices.gov.au/privacy or requesting a copy of the full privacy policy at one of our Service Centres.

Information for the doctor – continued

Request for clarification of additional information

Human Services, including staff from the Health Professional Advisory Unit, may make contact with you to discuss the information in your report. These contacts will only occur where information requires clarification.

Reimbursement for services

We have asked your patient to let you (and your receptionist) know at the time of making their appointment that they require you to complete this report. This is to ensure that you have sufficient time for the examination and completion of the report. The time taken to complete this report counts towards the length of the consultation. You can claim it as a long consultation.

For information about confidentiality and disclosure of information

See questions 9 and 12.

Thank you for your assistance.

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Please use black or blue pen.

1

This person has been:

my patient since

/

/

 

 

a patient at this practice since

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

2Does the patient have a medical condition that may significantly reduce their life expectancy?

No

You do not need to complete question 3. Go to 4

Yes

Diagnosis

Go to next question

3Is the average life expectancy of a person with this condition shorter than 24 months?

No

Yes

Go to next question

You do not need to complete questions 4 to 8. Go to 9

4Does the patient have one or more medical conditions that have a significant impact on their ability to function (e.g. endurance, walking, sitting, standing, performing daily activities, handling and manipulating objects, bending, self-care, concentration, attention, communication, hearing, vision, continence, consciousness)?

No

Yes

You do not need to complete question 5. Go to 6

Go to next question

5Give details about the conditions that have a significant impact on the patient’s ability to function.

List conditions in order of degree of impact on ability to function, starting with the condition with most impact. (see next page)

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Condition 1—condition with most impact

Diagnosis

ADiagnosis

Date of onset (if known)

The diagnosis is: Presumptive

Confirmed

/ /

Are further investigations/tests planned to confirm the diagnosis?

No

Yes

Is the diagnosis supported by further specialist opinion?

No

 

 

 

 

 

 

Yes

 

 

Give details below

 

 

 

 

 

 

 

 

 

Psychiatrist/

 

Name

 

 

 

 

 

 

Clinical Psychologist

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiologist/Ear, Nose

 

Name

 

 

 

and Throat specialist

 

 

 

 

 

 

 

 

 

 

 

 

Ophthalmologist Name

Other

Name and specialty

Are the relevant specialist reports available?

No

Yes

Attached

Will provide on request

Date of diagnosis

/ /

Treatment

BCurrent treatment

Provide details of all current treatment for this condition (e.g. hospitalisation, surgery, medication and dosage, counselling, physical therapy, rehabilitation, frequency of treatment)

Treatment

Date commenced

/ /

/ /

/ /

/ /

/ /

/ /

/ /

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Condition 1—continued

Treatment—continued

CPast treatment

Provide details of past treatment for this condition (e.g. hospitalisation, surgery, medication and dosage, counselling, physical therapy, rehabilitation, frequency of treatment)

Treatment type

Date commenced

Duration of treatment

/ /

/ /

/ /

/ /

/ /

/ /

DSpecialist consultation

Have you or another doctor from your practice previously referred this patient to a specialist?

No

Yes

Name

Give details below

Specialty

Date of consultation

/ /

/ /

/ /

/ /

EFuture/planned treatment

Provide details of any further scheduled or proposed treatment with estimates of likely dates of commencement and expected duration.

FPatient's compliance with recommended treatment

Very compliant

 

Usually compliant

 

Rarely compliant

Uncertain

Detail any issues related to accessing or undertaking suitable treatment that affect the level of compliance.

Clinical features

GCurrent symptoms

Describe current symptoms. Be specific and include severity, frequency and duration.

Note: symptoms are those persisting despite treatment, aids, equipment or assistive technology.

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Condition 1—continued

Clinical features—continued

HHistory

Provide details of underlying causes and contributing factors, results and dates of investigations/procedures and specialist consultations (e.g. radiology, pathology, RFTs, specialist reports).

Impact on ability to function

iDetails about how this condition and its treatment currently impact on the patient’s ability to function Be specific and consider the impacts on:

•endurance

•movement/dexterity (e.g. walking, bending, sitting, standing, lifting/carrying/manipulating objects)

•neurological/cognitive function (e.g. concentrating, decision making, memory, problem solving)

•functions of consciousness (details of involuntary loss of consciousness or altered consciousness (e.g. seizures, migraines)

•behaviour, planning, interpersonal relationships

•sensory function (e.g. seeing, hearing, speaking)

•digestive, reproductive, continence function

•need for care (e.g. support in daily living, support accommodation or nursing home/hospital care).

JThe impact of this condition on the patient’s ability to function is expected to persist for:

Less than 3 months

3-24 months

More than 24 months

KWithin the next 2 years the effect of this condition on the patient’s ability to function is expected to:

Resolve

Remain unchanged

Provide details

Significantly improve

Deteriorate

Slightly improve

Uncertain

Fluctuate

For a second condition that has a significant impact on ability to function, go to Condition 2, on the next page.

If there are no other conditions that have a significant impact on ability to function, go to question 6 on page 10.

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Condition 2

Diagnosis

ADiagnosis

Date of onset (if known)

The diagnosis is: Presumptive

Confirmed

/ /

Are further investigations/tests planned to confirm the diagnosis?

No

Yes

Is the diagnosis supported by further specialist opinion?

No

 

 

 

 

 

 

Yes

 

 

Give details below

 

 

 

 

 

 

 

 

 

Psychiatrist/

 

Name

 

 

 

 

 

 

Clinical Psychologist

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiologist/Ear, Nose

 

Name

 

 

 

and Throat specialist

 

 

 

 

 

 

 

 

 

 

 

 

Ophthalmologist Name

Other

Name and specialty

Are the relevant specialist reports available?

No

Yes

Attached

Will provide on request

Date of diagnosis

/ /

Treatment

BCurrent treatment

Provide details of all current treatment for this condition (e.g. hospitalisation, surgery, medication and dosage, counselling, physical therapy, rehabilitation, frequency of treatment)

Treatment

Date commenced

/ /

/ /

/ /

/ /

/ /

/ /

/ /

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Condition 2—continued

Treatment—continued

CPast treatment

Provide details of past treatment for this condition (e.g. hospitalisation, surgery, medication and dosage, counselling, physical therapy, rehabilitation, frequency of treatment)

Treatment type

Date commenced

Duration of treatment

/ /

/ /

/ /

/ /

/ /

/ /

DSpecialist consultation

Have you or another doctor from your practice previously referred this patient to a specialist?

No

Yes

Name

Give details below

Specialty

Date of consultation

/ /

/ /

/ /

/ /

EFuture/planned treatment

Provide details of any further scheduled or proposed treatment with estimates of likely dates of commencement and expected duration.

FPatient's compliance with recommended treatment

Very compliant

 

Usually compliant

 

Rarely compliant

Uncertain

Detail any issues related to accessing or undertaking suitable treatment that affect the level of compliance.

Clinical features

GCurrent symptoms

Describe current symptoms. Be specific and include severity, frequency and duration.

Note: symptoms are those persisting despite treatment, aids, equipment or assistive technology.

SA433.1207

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Condition 2—continued

Clinical features—continued

HHistory

Provide details of underlying causes and contributing factors, results and dates of investigations/procedures and specialist consultations (e.g. radiology, pathology, RFTs, specialist reports).

Impact on ability to function

iDetails about how this condition and its treatment currently impact on the patient’s ability to function Be specific and consider the impacts on:

•endurance

•movement/dexterity (e.g. walking, bending, sitting, standing, lifting/carrying/manipulating objects)

•neurological/cognitive function (e.g. concentrating, decision making, memory, problem solving)

•functions of consciousness (details of involuntary loss of consciousness or altered consciousness (e.g. seizures, migraines)

•behaviour, planning, interpersonal relationships

•sensory function (e.g. seeing, hearing, speaking)

•digestive, reproductive, continence function

•need for care (e.g. support in daily living, support accommodation or nursing home/hospital care).

JThe impact of this condition on the patient’s ability to function is expected to persist for:

Less than 3 months

3-24 months

More than 24 months

KWithin the next 2 years the effect of this condition on the patient’s ability to function is expected to:

Resolve Remain unchanged Provide details

Significantly improve Deteriorate

Slightly improve

Uncertain

Fluctuate

If there are more than 2 conditions that have a significant impact on ability to function, attach a separate sheet with details.

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6Does the patient have any other medical conditions that are generally well managed and that cause minimal or limited impact on ability to function?

No

Yes

Go to next question

Give details below

7Is there any other information that you would like to provide?

No

Go to next question

Yes

Give details below

8Do you wish to provide medical certificate details on this report?

No

Go to next question

Yes

Certification

I examined this person on

/

/

 

 

 

In my opinion this person is temporarily unfit for work or study from

/ /

to

/ /

In my opinion this person can

cannot

currently do their usual work or study or any other work for 8 hours or more per week.

9Release of medical information

The Freedom of Information Act 1982 allows for the disclosure of medical or psychiatric information directly to the individual concerned. If there is any information in your report which, if released to your patient, may harm his or her physical or mental well-being, please identify it and briefly state below why you believe it should not be released directly to the patient. Similarly, please specify any other special circumstances which should be taken into account when deciding on the release of your report.

Is there any information in this report which, if released to the patient, might be prejudicial to his/her physical or mental health?

No

Yes

Go to next question

Identify the information and state why it should not be released directly to the patient.

Once completed, please return this report directly to Disability Services, Reply Paid 7806, CANBERRA BC ACT 2610.

Continued

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10Would you like to discuss any aspects of this report with us? No

Yes Int

11If someone from Human Services, or another assessor nominated by us, needs to contact you to discuss any aspects of this report, what days/times suit you?

Day

Time

:am pm

:am pm

To

To

:am pm

:am pm

12

13

Confidentiality of Information The personal information that is provided to you for the purpose of this report must be kept confidential under section 202 of the Social Security (Administration) Act 1999. It cannot be disclosed to anyone else unless authorised by law. There are penalties for offences against section 202 of the Social Security (Administration) Act 1999.

Details of doctor completing this report

Please print in BLOCK LETTERS or use a stamp.

Name

Professional qualifications

Address

Postcode

Phone number

()

Signature

Date

/ /

Stamp (if applicable)

Returning this report

You can give this report and any attachments to your patient or you can return this report directly to us. However, if you answered ‘Yes’ at question 9, please make sure to return this report directly to Disability Services, Reply Paid 7806, CANBERRA BC ACT 2610.

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Stage no. 1 in filling out centrelink medical certificate form

2. Once your current task is complete, take the next step – fill out all of these fields - Please use black or blue pen, This person has been, my patient since, a patient at this practice since, Does the patient have a medical, Yes, You do not need to complete, Diagnosis, Go to next question, Is the average life expectancy of, Yes, Go to next question, You do not need to complete, and Does the patient have one or more with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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How you can fill out centrelink medical certificate form portion 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - A Diagnosis, Date of onset if known, The diagnosis is, Presumptive, Are further investigationstests, Yes, Confirmed, Is the diagnosis supported by, Yes, Give details below, Psychiatrist Clinical Psychologist, AudiologistEar Nose and Throat, Name, Name, and Ophthalmologist - to proceed further in your process!

Find out how to fill out centrelink medical certificate form part 4

5. While you approach the completion of your document, there are several extra things to complete. Mainly, Other, Name and specialty, Are the relevant specialist, Yes, Attached, Will provide on request, Date of diagnosis, Treatment, B Current treatment, Provide details of all current, Treatment, and Date commenced must all be filled in.

Tips on how to fill in centrelink medical certificate form portion 5

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