Verification of medical conditions form (SU684)

Use this form to verify medical conditions affecting your capacity to work if you need an Employment Services Assessment.

Download and complete the Verification of medical conditions form.

A medical practitioner must complete this form.

This is not a medical certificate. If you are seeking a temporary exemption from your Mutual Obligation or participation requirements because you are temporarily incapacitated for all work your treating doctor needs to complete a Medical Certificate.

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: 20 March 2020