Instructions

Medical certificate

Lodge online Functional impact of medical condition

If you are an eligible medical practitioner, you can complete Detail the day-to-day functional impact the listed medical
and lodge a Medical certificate (SU683) form online using condition(s) has on the patient, including how it affects their
Health Professional Online Services (HPOS). ability to work, study or participate in activities.
If you use HPOS, you do not need to complete this Medical Functional impacts may be physical and non-physical impacts
certificate (SU415) form. of a condition.
To find out more about HPOS, go to www.
Functional impact can include how well they can:
servicesaustralia.gov.au/hpos • sit or stand
• interact with other people
When to use this form • concentrate
Use this form if you are a medical practitioner and your • use their senses
patient is temporarily incapacitated due to a medical
condition. • undertake self-care (for example, showering, dressing,
grooming tasks).
Include any assistance or interventions that may help your
Important information patient to find and keep a job (for example, a rehabilitation or
The information you provide will help us make decisions about pain management program).
your patient, including:
• temporary exemption from Centrelink mutual obligation, Duration of functional impact
participation or study requirements Indicate the expected duration of the current functional impact
• additional assistance or support. of the medical condition, by selecting:
• up to to 13 weeks – current functional impact is expected
A medical certificate for a temporary incapacity should only be to fully resolve within 13 weeks (including a temporary
provided for the period medically required. exacerbation of a permanent condition).
• more than 13 weeks and up to 24 months – current
Information to help complete this form functional impact is expected to persist for more than
13 weeks and fully resolve within 24 months (including a
Diagnosis – conditions impacting work, study or
temporary exacerbation of a permanent condition). Your
participation in activities patient may be receiving treatment or rehabilitation for
List your patient’s diagnosed medical condition(s) that has cancer/leukemia, severe stroke, acquired brain injuries,
a functional impact on their ability to do any work, study or serious burns, and serious physical injuries. This could
participate in activities. Provide a specific clinical diagnosis, if include a severe mental health condition for which the
available, including staging and/or disease classification. person is receiving treatment in an institutional setting.
For example: • more than 24 months – current functional impact expected
• ‘cervical spondylosis’ rather than ‘neck pain’ to persist beyond 24 months and not likely to improve
• ‘major depressive disorder’ or ‘adjustment disorder with with treatment.
depressed mood’ rather than ‘depression’.
Capacity to work, study or participate in activities
If your patient has more than two conditions that have a This relates to your assessment of the patient’s capacity to
functional impact, you will need to provide the details on a do any work, study or participate in activities (for example,
separate medical certificate. looking for work, volunteering or attending appointments with
an Employment Service Provider).
Capacity to work includes any work that a person is capable of
doing, not just work the person has previously done, prefers or
what they are qualified for.
Capacity is not determined by non-medical factors
(for example, age, work experience, education or language
barriers).
Treatment
Detail past, current and future/planned treatment for the listed
medical condition(s).
This includes symptom management and functional
rehabilitation treatment, as well as curative treatment.

SU415.2501 Notes — 1 of 2
Additional information about temporary Confidentiality of information
exemptions and Centrelink requirements The personal information that is provided by your patient
for the purpose of this medical certificate must be kept
Temporary exemptions confidential under section 202 of the
Centrelink customers who receive an income support Social Security (Administration) Act 1999.
payment may be required to actively seek work, study and/or It cannot be disclosed to anyone else unless authorised by
participate in activities to help them find and keep work. law. There are penalties for offences against section 202 of
A temporary exemption from their requirements may be the Social Security (Administration) Act 1999.
granted by Services Australia for the period where a patient’s
capacity to work, study or participate in activities is less than
8 hours per week. Release of medical information
Where a patient has a medical condition that reduces their The Freedom of Information Act 1982 allows for the disclosure
capacity to work, study or participate in activities of 8 hours or of medical or psychiatric information directly to the individual
more per week, a Services Australia allied health professional concerned. If there is any information in the medical
may conduct an assessment to determine the most certificate, which, if released to your patient, may harm their
appropriate support program or align activities to the patient’s physical or mental well-being, attach a statement identifying
capacity. the information and briefly state why you believe it should not
be released directly to the patient. Similarly, specify any other
Exemptions for people with a serious illness special circumstances, which should be taken into account
A serious illness exemption may be granted for some when deciding on the release of the medical certificate.
payments. A serious illness can include:
• cancer/leukemia For more information
• severe stroke If you need help to complete this form or selecting the
appropriate consultation item for completing this form,
• acquired brain injury call 132 150 Monday to Friday, 8:30 am to 5 pm, local time.
• severe burns
• severe physical injury requiring long recovery period Returning this form
• severe mental health conditions with treatment in an Return this form and any supporting documents to your
institutional setting. patient to lodge with Services Australia or upload using their
Centrelink online account through myGov.

SU415.2501 Notes — 2 of 2
 Instructions

Medical certificate
(SU415)
* Denotes mandatory question Centrelink customers can lodge this medical certificate using their Centrelink online account
through myGov. For help, go to servicesaustralia.gov.au/centrelinkuploaddocs
www.

Patient’s details
CRN Date of birth
(DD MM YYYY)
Family name
Home address
First name

Second name Postcode

Condition(s) impacting work, study or participation in activities Functional impact for listed condition(s)
Primary condition
* Specific diagnosis

Past, current and planned treatment for listed condition(s)

Date of onset (if known)
(DD MM YYYY)
* The duration of the current functional impact of this condition is expected
to be (including a temporary exacerbation of a permanent condition):
up to 13 weeks more than more than 24 months
13 weeks and up
to 24 months
Will this result in an average life expectancy of 24 months or less? Other condition(s)
No Is there any other condition(s) impacting capacity to work, study or
participate in activities?
Yes
No
Does this condition meet one of the serious illness categories outlined on Yes You need to complete and return a separate
page 2 of the Notes?
Medical certificate (SU415) form.
No
Yes Your details
Doctor’s name (type or print in BLOCK LETTERS)
Secondary condition
* Specific diagnosis
Qualification(s)

Provider no.
Surgery/Medical centre/Hospital name
Date of onset (if known)
(DD MM YYYY) Address
* The duration of the current functional impact of this condition is expected
to be (including a temporary exacerbation of a permanent condition):
up to 13 weeks more than more than 24 months
13 weeks and up Postcode
to 24 months
Phone number
Capacity to work, study or participate in activities (including area code)
Signature
* How long is this incapacity expected to last?
From (DD MM YYYY) To (DD MM YYYY) On completion of this form,
print and sign by hand

Can this patient do any work, study or participate in activities of 8 hours Date (DD MM YYYY)
or more per week?
No
Yes How many hours can they work, study or participate in
activities on average each week?
CLK0SU415 2501

SU415.2501 1 of 2 Clear
Privacy notice Privacy and your personal information
The privacy and security of your personal information is important to us, and is protected by law.
We collect this information so we can process and manage your applications and payments,
and provide services to you. We only share your information with other parties where you have
agreed, or where the law allows or requires it. For more information, go to www.

servicesaustralia.gov.au/privacypolicy

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