Oral Health Services Tasmania
CONSENT FOR CENTRELINK CONFIRMATION
TITLE:
Mr / Mrs / Ms / Miss
SURNAME:
GIVEN NAMES:
DOB:
This consent will be used for the sole purpose of authorising Centrelink to provide information
to Oral Health Services Tasmania to assess your eligibility in relation to concessions or services
provided by Oral Health Services Tasmania.
I …………………………………………………………………….. authorise Centrelink to
confirm with Oral Health Services Tasmania the current status of my Commonwealth Benefit
and other details as they pertain to my concessional entitlement. This involves electronically
matching details I have provided to Oral Health Services Tasmania with Centrelink or
Department of Veterans’ Affairs (DVA) records to confirm whether or not I am currently
receiving a Centrelink or DVA benefit.
I understand that this consent, once signed, is effective only for the period I am a client of Oral
Health Services Tasmania. I also understand that this consent, which is ongoing, can be
revoked any time by giving notice to Oral Health Services Tasmania.
I understand that if I withdraw my consent, I may not be eligible for the concessions provided
by Oral Health Services Tasmania.
Dated this:
day of
20
Client Signature:
Confidentiality Note: The use of your personal information is subject to the provisions of the Personal
Information Protection Act 2004 (PIP). More information about PIP can be obtained from your OHST clinic, other
DHHS office, or at www.dhhs.tas.gov.au on the internet.
OHST-FRM-057
Issue Date: 14/06/2012
Version: 1.0