Fillable Claim for DSP Medical Evidence Checklist Evidence

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Claim for Disability Support Pension > Medical Evidence Checklist > Medical Evidence Requirements. Medical evidence to support your claim for Disability Support Pension. Medical evidence includes documents written by a registered medical practitioner (such as your treating doctor) and other registered health or allied health professionals. This evidence should support the information you provide in the medical details section of your claim.Statements about your condition written by you or your nominee are taken into account, but are not considered medical evidence. This applies to information provided by a person who is not a registered health professional, such as a teacher

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The Claim for DSP Medical Evidence Checklist Evidence form is 3 pages long and contains:

  • 1 signature
  • 29 check-boxes
  • 11 other fields

Country of origin: AUSTRALIA
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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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1 of 3
SA473.1705
Claim for Disability Support Pension
Medical Evidence Checklist
Medical Evidence Requirements
Medical evidence to support your claim for
Disability Support Pension
You need to provide current medical evidence from your treating health
professional(s) to support your claim for Disability Support Pension.
We need this information to help us understand how your medical
conditions affect you, and to make sure we correctly assess your
claim.
We are not responsible for obtaining this information on your
behalf. However, we may contact your treating health professionals
to confirm or clarify information you provide about your medical
conditions.
Information we need to assess your claim
You must provide current medical evidence about each of your
medical conditions that impact your ability to work. These
requirements are explained in more detail below.
You need to provide suitable medical evidence when you lodge your
claim. If you do not provide this information we may be unable to
correctly assess your claim, and may reject your claim.
Please tell us if you cannot provide evidence within that time, or if
you are having difficulty obtaining medical evidence.
What is medical evidence?
Medical evidence includes documents written by a registered medical
practitioner (such as your treating doctor) and other registered health
or allied health professionals. This evidence should support the
information you provide in the medical details section of your claim.
Statements about your condition written by you or your nominee are
taken into account, but are not considered medical evidence. This
applies to information provided by a person who is not a registered
health professional, such as a teacher.
Examples of medical evidence you may be required to provide:
• medical history reports/print outs
• specialist medical reports, including outcomes of specialist
referrals by your treating doctor
• allied health professional reports, such as physiotherapy or
audiology reports
• psychologist reports, including IQ testing reports
• medical imaging reports
• compensation and rehabilitation reports
• physical examination reports
• hospital/outpatient records or discharge summaries including
operations you have had.
You are not required to provide everything on this list. Medical
evidence should be as current as possible. Older evidence (such as
reports or records more than 2 years old) will generally be considered
less relevant. Please talk to your treating health professional if you
are not sure whether the medical evidence you have reflects your
current circumstances.
Details of your treating health professionals
Please include the full name and contact details for all your treating
health professionals in the medical details section of your claim.
Information we need about your medical conditions
In most cases, we need current information about the diagnosis,
treatment, symptoms, functional impact and prognosis of each of the
medical condition(s) that impact your ability to work. This is explained
in more detail below:
Diagnosis
• The formal diagnosis of the medical conditions that impact your
ability to function.
• When each medical condition was diagnosed.
• The name, qualification and contact details of the medical
professional who made the diagnosis.
Treatment and care
• The type of treatment that has been undertaken in the past.
• The current treatment(s) you are undertaking.
• Planned or future treatment, including whether you are on a
waiting list.
• If you require specific care because of your condition, including
nursing home level or palliative care.
Symptoms and functional impact
• When the symptoms of each medical condition started (date of
onset).
• Current symptoms of your conditions (persisting despite treatment,
aids, equipment or assistive technology).
• The severity, frequency and duration of your symptoms.
• How your conditions and treatment impact on your ability to
function in day-to-day life including at work.
Prognosis
• The length of time the condition is likely to impact your ability to
function.
• Whether the condition is likely to improve, remain the same or get
progressively worse.
• Whether your medical condition is likely to significantly affect your
life expectancy.
Specific medical evidence required for some medical
conditions
We need specific medical evidence for some medical conditions.
This includes:
•
ear conditions affecting hearing or balance:
the diagnosis must
be supported by a report from your audiologist or ear, nose and
throat specialist.
•
eye conditions affecting vision:
the diagnosis must be supported
by a report from your ophthalmologist.
•
mental health conditions (such as depression, schizophrenia):
your doctor’s diagnosis must be supported by a psychiatrist or
clinical psychologist assessment.
•
intellectual impairment:
we need an assessment of intellectual
function and assessment of adaptive behaviour from your
psychologist, or a report from your special school which includes
these psychologist assessments. Evidence you provide must
include information supported by a psychologist about your IQ
score, or your ability to undergo IQ testing.
For more information, go to
humanservices.gov.au/dsp
or call us
on 132 717.
SA473.1705
2 of 3
Claim for Disability Support Pension
Medical Evidence Checklist
CLK0SA473 1705
This checklist helps ensure you have the right medical evidence to support your claim for Disability Support Pension. It may also help guide
discussion with your treating health professionals if you need further evidence. Disability Support Pension medical evidence requirements are
explained on page 1 of this form and on page 31 of the claim form. For more information, go to
humanservices.gov.au/dsp
Your details
Family name
Given name(s)
Centrelink
Reference Number
Date of birth
/ /
1
Do you have current medical evidence from your treating doctor(s)
for any conditions which significantly affect your work capacity?
No
Yes Go to next question
Go to 3
2
In most cases we need medical evidence from your treating
doctor(s) to include your diagnosis, prognosis and how your
condition affects you. Please indicate the information included in
the medical evidence from your treating doctor(s):
the diagnosis of any conditions which significantly affect
your work capacity
details of the treating health professional (s) who
diagnosed each condition, including names and contact
details
details of any past, current and planned treatment for your
conditions
symptoms of your conditions (how they affect you now, and
how they may affect you in the future, with treatment)
prognosis for your conditions, (taking into account any
current and planned treatment)
3
Please indicate which statement applies to you.
You are claiming Disability Support Pension because:
you need nursing home level care, or your life expectancy is
significantly reduced within the next 2 years
of an intellectual disability
of an eye condition affecting your vision
You will need to provide medical evidence that
outlines your symptoms and prognosis.
You will need to provide an assessment of intellectual
function and adaptive behaviour supported by a
psychologist, including information about your
IQ score, or your ability to undergo testing.
You will need to provide an
Optometrist/
Ophthalmologist Report
form (
SA013
) or equivalent
information.
you are permanently blind
of a mental health condition (such as depression or anxiety)
of an ear condition affecting your hearing or balance
You will need to provide an
Optometrist/
Ophthalmologist Report
form (
SA013
) or equivalent
information.
You will need to provide evidence that the diagnosis
was made by a psychiatrist,
OR
another medical
practitioner (such as your GP)
and
a clinical
psychologist.
You will need to provide evidence that the diagnosis
is supported by an ear, nose and throat specialist
or
another medical practitioner (such as your GP)
and
an audiologist.
none of the above
SA473.1705
3 of 3
4
What medical evidence documents are you providing with your
claim?
Medical history records, such as a patient health summary
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
Report from another treating health professional such as
a physiotherapist, psychologist, occupational therapist or
audiologist
Rehabilitation reports
Medical imaging report such as MRI, X-ray, CT
(films not required)
Hospital / Outpatient / Discharge report
Compensation medical report
Wait-list confirmation letter
Special School/Special Education Unit report
Other medical evidence – give details below
Please provide existing medical evidence with your claim which
shows the current impact of your condition(s). If you have given
any of these documents to us before, you do not need to provide
them again.
5
Are you having difficulty getting medical evidence, or giving
evidence to us?
No
Go to next question
To help us understand your situation, please explain
why you are having difficulty with medical evidence.
Yes
6
We may need to contact your treating health professional(s)
about your medical condition(s). They may ask us to confirm
that you have provided consent in writing for them to
disclose information about your medical conditions. You
can do this by completing a
Consent to disclose medical
information
form (
SA472
).
Have you completed and given us a
Consent to disclose
medical information
form?
No
Yes Go to next question
To provide consent, you will need to complete
a
Consent to disclose medical information
form (
SA472
).
If you do not have this form, go to
humanservices.gov.au/forms
Go to next question
IMPORTANT INFORMATION
Privacy and your personal information
Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Your information may be used by the department, or given
to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
You can get more information about the way in which the
department will manage your personal information, including
our privacy policy, at
humanservices.gov.au/privacy
7
Statement
I declare that:
• the information I have provided in this form is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services
can make relevant enquiries to make sure I receive the
correct entitlement.
8
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Date
/ /
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SA473.1705 Claim for DSP Medical Evidence Checklist Evidence

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Completed 12 August 2019

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