Medicare Compensation Recovery Medicare history statement request form (MO026)

Use this form to get a copy of your Medicare history statement, to find out what benefits and subsidies need to be repaid to us as per a Notice of past benefits.

Download and complete the Medicare Compensation Recovery Medicare history statement request form.

You, an authorised third party or the person paying your compensation can request a copy of your statement. This form is the first step in requesting a Notice of past benefits under Section 21 of the Health and Other Services (Compensation) Act 1995.

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: 10 December 2021