Supporting Leave for Living Organ Donors
Self-Employed claim
Purpose of this form
The information on this form will be used to verify your claim and
calculate the payment that will be made to you as a contribution toward
reimbursing you for income lost as a result of living organ donation.
PART A — Self-employed donor to
complete
Donor details
How the process works
Use this form once you return to work, to make a claim for your workup and leave following donation surgery.
1
Dr ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other
Family name
Payment will be based on the amount of leave you have taken. A
maximum of 9 weeks (342 hours) may be claimed.
If you are deemed medically not eligible to donate following work-up,
you can still submit a claim for up to 2 weeks of formal leave taken to
attend the tests. A minimum of 1 days (7.6 hours) leave must have
been taken to be able to make a claim.
Prior to completing and submitting the Self-employed claim form, you
need to have completed and submitted the Individual registration
form.
Once your claim has been received, an amount will be calculated and
transferred via Electronic Funds Transfer (EFT) to your nominated bank
account.
First given name
Other given name(s)
Work up tests and/or donation details
2
Hours of leave taken for work-up
3
Did you proceed to donation following your work-up?
No
☐> Go to 7
Yes
☐
4
Date of surgery
A confirmation letter will then be sent to you.
Filling in this form




Please use black or blue pen
Print in BLOCK LETTERS
Mark boxes like this ☐ with a ✓ or x
Where you see a box like this ☐> Go to 5 skip to the question
number shown. You do not need to answer the questions in
between.
/ /
5
Hours of leave taken for surgery and recovery
6
Period of leave taken
Returning your form
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Send the completed form to:
Department of Health
Supporting Leave for Living Organ Donors Programme
GPO Box 9848
Canberra ACT 2600
/ /
From
7
/ /
Total amount of leave taken
weeks
Or send a scanned copy of the completed form via email to:
livingorgandonation@health.gov.au
to
days
You must attach a Doctor’s certificate(s) to support the
amount of leave you have taken.
For more information
The department has information on the Supporting Leave for Living
Organ Donors Programme on our website, or for assistance completing
this form call (02) 6289 5055 Monday to Friday, between 8.30 am and
5.30 pm Australian Eastern Standard Time.
Employment details
8
Business name
Note: Call charges apply – calls from mobile phones may be charged at
a higher rate.
Trading name (if different to above)
Page 1 of 3
PART B — Medical Professional to
Postal address
………………………………………………….……..………..
complete
…………...………………………………………...……………
State
Postcode
Please note
This part can be completed by a transplant coordinator or a medical
practitioner.
Email
Medical Practitioner details
9
Australian Business Number (ABN)
-
-
14 Dr ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other
-
Family name
10 Industry Type:
Private Sector
☐
Local Government ☐
Cwth Government ☐
State Government ☐
First given name
11 Small Business?
Yes
No
Donation details
☐
☐
15 Did the donation proceed?
Bank account details
No
Yes
All payments are made through Electronic Funds Transfer (EFT) and
cannot be made into credit card, loan or mortgage accounts.
12 Name of bank, building society or credit union
☐> Go to 17
☐>Date of surgery for donation
/ /
16 Organ donated
Kidney
Partial Liver
Branch where the account is held
☐> Go to 18
☐> Go to 18
17 Reason the donation did not proceed
Medically not eligible
Other
Branch number (BSB)
☐
☐> Give details
…………………………………………………......…
Privacy notice
Account number
18 Your personal information is protected by law, including the
Privacy Act 1988, and is being collected by the Australian
Department of Health for the purpose of assessing your
patient’s eligibility for financial assistance under the Supporting
Leave for Living Organ Donors Programme and administration
of the Programme.
Account name
Donor declaration
13 I declare that:
 I confirm the payment I receive under the programme is to be used
as reimbursement for my lost income due to donating an organ.
The Department of Health can be contacted on (02) 6289 5055
or by using the Support for Living Organ Donors online
enquiries form.
 the information I have provided in this form is complete and correct.
If you do not provide this information the Department of Health
may be unable to assess your patient’s eligibility and process a
claim for payment under this Programme.
 I have attached the doctor’s certificate(s) that support(s) the amount
of leave I have taken.
The Department has an Australian Privacy Principles (APP)
privacy policy which you can read online.
I understand that:
The APP privacy policy contains information about:
 giving false or misleading information is a serious offence.
Donor signature

Date

/ /
Page 2 of 3
how you may access the personal information the
Department holds about you and how you can seek
correction of it; and
how you may complain about a breach of the Australian
Privacy Principles
Medical Practitioner declaration
19 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.
Medical Practitioners signature
Date
/ /
Page 3 of 3