Carer Payment Allowance Medical Report

Carer Payment and Carer Allowance – Medical Report (for a child under 16 years)

Child’s details

You will need to provide a separate report for each child – Contact us if you require additional reports.

Child name:

Date of birth: CRN:

Carer’s details

Carer name:

Address:

Postcode:

Date of birth: CRN:

Phone number:

Instructions for the parent/guardian (carer)

Give this report to the child’s doctor or treating health professional to complete.

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.

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.

Authority to release information

I give permission for medical details and clinical notes about the child to be supplied to the Australian Government Department of Human Services.

I understand that the report will be used to assist in assessing a claim for Carer Allowance for current and future carers and may need to be released to that person(s) by the Department of Human Services.

Carer signature: Date:

Health professional report

1. Disability or medical condition(s)

Primary disability or medical condition:

Other disability or medical condition(s):

2. Did the disability or medical condition commence more than 12 weeks ago?

No

Yes

3. What date did the disability or medical condition commence?

4. Is the child’s condition:

Permanent

Temporary

5. Is the permanent condition:

Non improving

Improving

6. Is the temporary condition expected to be present for:

At least 12 months

Less than 12 months

7. Does the condition require extra care and attention for 14 hours or more per week?

No

Yes

8. Recognised disabilities and medical conditions

Cerebral Palsy where the child is dependent on a stroller, wheelchair, or walking frame

Lower Limb Deficiencies where the child is dependent on a stroller, wheelchair, or walking frame

Spina Bifida where the child is dependent on a stroller, wheelchair, or walking frame

Other moderate to severe multiple or physical disability

Epilepsy - Absence Seizure (Petit Mal)

Epilepsy - Grand Mal (Tonic-Clonic)

Epilepsy - Myoclonic Seizure

Epilepsy - Complex Seizure

Epilepsy - Simple Seizure

Down Syndrome

Fragile X Syndrome

9. Medical conditions

Chronic or end stage organ failure

HIV/AIDS

Immunodeficiency requiring regular immunoglobin infusions

Leukemia or other childhood malignancies

Haemophilia

Thalassaemia or Haemoglobinopathy

Chronic transfusion dependent anaemia

Langerhan Cell Histiocytosis

Severe congenital Neutropenia

10. Does the child have a disability or medical condition listed at question 8 or 9?

No

Yes

11. Please read this before answering the following questions.

The child is considered to have the functional ability to do certain things if he/she can do the task given the opportunity, consistently or on a daily basis, and to a reasonable standard.

12. Receptive language skills

Child’s ability is age appropriate.

Child understands adult speech or signed language of normal speed and complexity.

Child cannot do any of the things listed above.

13. Expressive language skills

Child’s ability is age appropriate.

Child has almost a full adult vocabulary.

Child cannot do any of the things listed above.

14. Feeding and mealtime skills

Child’s ability is age appropriate.

Child can use a fork and spoon at mealtimes.

Child cannot do any of the things listed above.

15. Hygiene and grooming skills

Child’s ability is age appropriate.

Child is reliably toilet-trained during the day and can manage own toileting with minimal assistance.

Child cannot do any of the things listed above.

16. Dressing skills

Child’s ability is age appropriate.

Child can dress and undress without any assistance.

Child cannot do any of the things listed above.

17. Social and community skills

Child’s ability is age appropriate.

Child can use all major community facilities with little assistance.

Child cannot do any of the things listed above.

18. Mobility — fine motor skills

Child’s ability is age appropriate.

Child can write clearly.

Child cannot do any of the things listed above.

19. Mobility — gross motor skills

Child’s ability is age appropriate.

Child can walk and can run a few steps.

Child cannot do any of the things listed above.

20. Behaviour

Child is consistently uncooperative and disruptive during treatment or assessment episodes.

Child demonstrates self injurious behaviour.

Child displays aggressive behaviour or violence towards other people or property.

Child persistently attempts to leave or abscond.

Child is extremely active and is unable to concentrate on a task for more than 30 seconds.

None of the above apply.

21. Special care needs

Child receives all food and fluids by nasogastric, gastrostomy or PEG tube.

Child is receiving a course of chemotherapy or radiotherapy treatment for cancer.

Child requires regular oxygen therapy at home.

Child requires a wheelchair and requires assistance to propel the wheelchair.

None of the above apply.

22–27. Personal care and care load

Does the child need personal care for a significant period everyday?

Does the child have a condition that may significantly reduce their life expectancy?

Is the average life expectancy substantially longer than 24 months?

Is the care load so high that more than one carer is required?

How many carers are required?

28–32. Additional care duration

For 6 months or more

For 3 to less than 6 months

Not sure

Start date: End date:

Is the child likely to have future episodes of the same or a similar condition?

33. Legally qualified medical practitioner

Yes

No

Practitioner name:

Professional qualifications:

Contact phone number:

Address:

Postcode:

34. Other comments

35. Release of medical information about the child requiring care

No

Yes

36. Identify the information and state why it should not be released

Details of Medical Practitioner or treating health professional completing this report

Name:

Professional qualifications:

Contact phone number:

Address:

Postcode:

Medicare Provider Number:

Name of health or disability service employer:

37. 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.

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.

38. Returning this report

You can give this report and any attachments to the carer or you can return this report directly to us.

Name:

Professional qualifications:

Contact phone number:

Address:

Postcode:

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