Verification of Terminal Illness form (SA495)

Use this form to verify your patient’s terminal illness when they’re applying for Disability Support Pension (DSP).

Download and complete the Verification of Terminal Illness form.

Only complete it if you haven’t completed the verification section in the Claim for DSP for a Terminal Illness form.

For DSP, a terminal illness means the average life expectancy for a person with this condition is less than 2 years.

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 contact us. We can help you access, complete and submit them.

Page last updated: 8 December 2020