Exemption From Income Management Form
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Note:
This form may only be used for children under the compulsory school-age
The information on this form is used to provide Centrelink with the required evidence when clients are seeking an
exemption from income management
The form must be completed by a Registered Health Practitioner
A copy of the form must be retained in the client medical record (scanned into PCIS)
The original form must be handed to the client as required by Centrelink
Family Details
Child’s name
Child’s Date of Birth
Parent/Carer Name
Health Checks and Immunisations
Please circle
Has received all age-appropriate immunisations
Yes / No
This includes:
children who have a medical reason for not receiving the appropriate level of immunisation
OR
-
children for whom a conscientious objection form has been lodged with the Aust Childhood Imm Register (ACIR)
-
Yes / No
In the last 12 months has completed the age-appropriate health checks
Has undertaken any relevant and available medical therapy (if applicable)
Yes / No
For example Speech Therapy, Physiotherapy, Occupational Therapy
Declaration
I ________________________________________________________, declare that the
(Name of Registered Health Practitioner)
information provided is true and correct.
Please print
Position
Health Centre Name
Signature
Date
Form developed by:
Best Practice Group
Form endorsed by:
Best Practice Group
Release Date: November 2010
Reviewed: June 11, Feb 12,
Review Due: February 2015
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Parent category: Financial