in BLOCK LETTERS surgery dates and support the amount of leave you have taken. Mark boxes like this with a or x ✓ you see a box like this > Go to 5 skip to the Out-of pocket expenses question number shown. Are you claiming for out-of-pocket expenses related Returning your form to donor travel and accommodation incurred as a Check that you have: answered all questions you need to result of your donation? answer; signed and dated this form; and attached: Yes > Go to 9 No > Go to 11 Donors: A medical certificate(s)/ appointment tracker to confirm Amount of out-of-pocket expenses to be claimed your appointment and surgery and support the amount of leave/ time off you have taken You must attach a receipt(s) to support the Receipts to support the out-of-pocket related to out-of-pocket costs (donor accommodation donor travel and accommodation being claimed and travel) being claimed. Employers: Evidence (payslips/ reports) that the claimed leave Bank account details and/or ex-gratia payment/s have been made to your employee. All payments for out-of-pocket expenses are made through EFT and cannot be made into credit card, loan PART A - Donor or mortgage accounts. Name of bank, building society or credit union Donor details name Branch where the account is held Program reference number Postal address Branch number (BSB) - Email I am claiming for leave taken for: Account number Work-up testing > Go to 3 Work-up testing and donation > Go to 3 Account name Donation only > Go to 5 Work-up test details Privacy notice Hours of leave taken for work-up Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Did you proceed to donation following your work-up? Australian Department of Health for the purpose of No > Go to 8 Yes assessing your eligibility for financial assistance under the Supporting Living Organ Donors Program and Donation details administration of the Program. Date of surgery 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 Program. Hours of leave taken for donation The Department has an which you can read online. The APP privacy policy contains information on: Period of leave taken to how you may access the personal information the Department holds about you and how you can seek You must attach evidence (e.g. medical correction of it; and certificates) to confirm your appointment and
in BLOCK LETTERS Mark boxes like this with a ✓ or x you see a box like this > Go to 5 skip to the question number shown. Returning your form Check that you have: answered all questions you need to answer; signed and dated this form; and attached: Donors: A medical certificate(s)/ appointment tracker to confirm your appointment and surgery and support the amount of leave/ time off you have taken Receipts to support the out-of-pocket related to donor travel and accommodation being claimed Employers: Evidence (payslips/ reports) that the claimed leave and/or ex-gratia payment/s have been made to your employee. PART A - Donor Donor details name Program reference number Postal address Email I am claiming for leave taken for: Work-up testing > Go to 3 Work-up testing and donation > Go to 3 Donation only > Go to 5 Work-up test details Hours of leave taken for work-up Did you proceed to donation following your work-up? No > Go to 8 Yes Donation details Date of surgery Hours of leave taken for donation Period of leave taken to You must attach evidence (e.g. medical certificates) to confirm your appointment and surgery dates and support the amount of leave you have taken. Out-of pocket expenses Are you claiming for out-of-pocket expenses related to donor travel and accommodation incurred as a result of your donation? Yes > Go to 9 No > Go to 11 Amount of out-of-pocket expenses to be claimed You must attach a receipt(s) to support the out-of-pocket costs (donor accommodation and travel) being claimed. Bank account details All payments for out-of-pocket expenses are made through EFT and cannot be made into credit card, loan or mortgage accounts. Name of bank, building society or credit union Branch where the account is held Branch number (BSB) - Account number Account name Privacy notice Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Department of Health for the purpose of assessing your eligibility for financial assistance under the Supporting Living Organ Donors Program and administration of the Program. 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 Program. The Department has an which you can read online. The APP privacy policy contains information on: how you may access the personal information the Department holds about you and how you can seek correction of it; and