Authorisation to act on an incapacitated person's behalf for Medicare purposes form (MO050)

Use this form if you want to act on behalf of someone who is incapable of managing their own affairs for Medicare services.

Download and complete the Authorisation to act on an incapacitated person's behalf for Medicare purposes form.

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, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 11 February 2020