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.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

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: 17 November 2022.
QC 52650