Medicare Compensation Recovery Section 23A Statement form (MO023)

Use this form to declare you received no benefits, or received no further benefits since your most recent expired notice, for your compensable injury or illness.

Download and complete the Medicare Compensation Recovery Section 23A Statement form.

The injured person (or claimant) may give this statement to us only if declaring that a Notice of past benefits has never been issued in relation to the case for compensation or a Notice of past benefits has previously been issued, but had expired at the time of judgment or settlement.

You can fill in this form and sign it digitally. You can do this by downloading it on a computer or a device that has Adobe Acrobat Reader. If you don’t have Adobe Acrobat Reader you can print it and sign it by hand.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 3 December 2020