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Instructions
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Authority to Release
Personal Information – Personal Injury,
Insurance, Superannuation or Other Matter
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Purpose of this form
This form is used to obtain your consent for the Australian Government
Department of Human Services to provide certain information about
you, regarding Centrelink payments and services, to a law firm, an
insurance company, a superannuation fund, another government agency
or other third party organisation, where the information sought can be
disclosed under our administrative access scheme.
Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
No
Go to next question
Yes
Give details of other name(s)
Under our administrative access scheme, we will provide Centrelink
payment tax summary information (some payments may not be included),
earnings information, medical certificate information and medical, Job
Capacity Assessment and Employment Services Assessment reports
(and/or other specific information), or a combination of these items,
for certain periods, as specified on this form.
If you require more space, attach a separate sheet
with details.
Not all your personal information may be released under this scheme.
Some information may need to be considered formally under other
legislation. We will advise the third party if this is required.
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Your personal information is disclosed in accordance with the general
consent provisions contained in social security law.
Your date of birth
dd
This form should not be used if you need compensation recovery advice.
For more information, go to our website
humanservices.gov.au/centrelinkcompensationrecovery
www.
/ mm /
yyyy
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Your Centrelink Reference Number (if known)
5
Your postal address
Filling in this form
•
•
•
•
Please use black or blue pen.
Print in BLOCK LETTERS.
with a or .
Mark boxes like this
Go to 5 skip to the question
Where you see a box like this
number shown. You do not need to answer the questions in
between.
Postcode
Returning your form(s)
Check that you have answered all the questions you need to answer
and that you have signed and dated this form. Forms that are incomplete
may not be processed.
Return this form to the third party indicated at question 7.
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The third party should fax this completed form to the Information
Release Team on 1300 080 619. Alternatively, this form can be scanned
and emailed to tpo.consent@humanservices.gov.au
1
Have you ever claimed or received a Centrelink payment or
service?
No
Go to next question
Yes
Give details below
Your name
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
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7
Details of the third party organisation (i.e. who is requesting your
information and where your information is to be sent).
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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 for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.
Name
Address
Postcode
Third party reference number (if known)
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www.
Select and complete each item you are consenting to release.
Note: The release of this information is not compensation advice.
10 Declaration or Authorisation by another person
If the person cannot consent to the release of their own personal
information (e.g. they are a child, they have a Power of Attorney
or they are deceased), and another person can authorise the
release, complete the following:
Type and amount of Centrelink payments (some payments
may not be included)
for the period by Fortnight
OR
Financial year
from
to
/
/
IMPORTANT INFORMATION
/
Reason for authorisation by another person
/
Details of earnings from employment for the period
from
to
/
/
/
/
Position held
Medical certificate information, medical, Job Capacity
Assessment and Employment Services Assessment reports
from
to
/
/
/
Print name
/
Note: If you are authorising the release of a deceased person’s
information, there may be limits to who can authorise the
release (i.e. the Executor) and what can be released under this
administrative access scheme. Proof will also be required.
Other – Give details below
Statement
I declare that:
• the information I have provided on this form is complete and
correct.
• I give my consent for the Australian Government Department
of Human Services to provide the personal information as
authorised on this form, to the third party indicated at
question 7.
I understand that:
• this authority remains valid for a period of 12 months from
the date it is signed and dated, unless revoked by me
beforehand.
Your signature
On completion of this form,
please print and sign by hand.
Date
/
/
Print
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See Page 1 for instructions on returning this form.
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