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 theMedicare 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.

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: 11 February 2020