Application for a Health Care Card

for former recipients of a

Carer Allowance Health Care Card

Purpose of this form If your parent or carer previously had a Carer Allowance Health Care Card (under 16) for you,
you may be eligible for a Health Care Card if you are a full-time student and are under 26 years
of age.
You will need to complete this form to apply for a Carer Allowance Health Care Card in your own
name (not in your carer’s name).

Online Services You can complete and submit this claim electronically at
humanservices.gov.au/excarerallowancecard
You can access your Centrelink online account through myGov. myGov is a simple and secure
way to access a range of government services online with one username and password. You can
create a myGov account at my.gov.au and link it to your Centrelink online account. To make a
claim online, access your Centrelink online account through myGov, then select ‘Online Claims’
from the menu.

Filling in this form • Please use black or blue pen.

• Print in BLOCK LETTERS.
• Mark boxes like this with a or .
• Where you see a box like this Go to 5 skip to the question number shown. You do not need
to answer the questions in between.

Returning your form Check that all required questions are answered and that the form is signed and dated.
Important Note: You must return all supporting documents at the same time you lodge this claim
form. If you do not return all documents, your claim may not be accepted. The only exception will
be if you are waiting for medical evidence or other documents from a third party.
You can return this form and any supporting documents:
• online – submit your documents online (excluding identity documents). For more information
about how to access an Online Account or how to lodge documents online, go to
humanservices.gov.au/submitdocumentsonline
• by post – return your documents by sending them to:
Department of Human Services
PO Box 7800
CANBERRA BC ACT 2610
• in person – if you are unable to submit this form and any supporting documents online or by
post, you can provide them in person to one of our service centres.

For more information Refer to Information you need to know about your claim for Commonwealth Seniors Health
Card, Low Income Health Care Card, Foster Child Health Care Card and Ex-Carer Allowance
(Child) Health Care Card (Ci010) (Information Booklet) at
humanservices.gov.au/excarerallowancecard
If you need a translation of any documents for our business, we can arrange this for you free
of charge.
To speak to us in languages other than English, call 131 202.
Note: Call charges may apply.
If you have a hearing or speech impairment, you can contact the TTY service on
Freecall™ 1800 810 586. A TTY phone is required to use this service.

Please keep these Notes (pages 1 and 2) for your information.

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Confirming your You may be required to confirm your identity when claiming a Health Care Card for former
identity recipients of the Carer Allowance Health Care Card (under 16). To confirm your identity, you must
provide original documents (not copies).
For a list of acceptable documents, refer to Confirming your identity in the Information Booklet.
If you have any difficulty in obtaining or providing these documents, you should contact us as soon
as possible.

Please keep these Notes (pages 1 and 2) for your information.

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 Instructions

Application for a Health Care Card

for former recipients of a
Carer Allowance Health Care Card

1 Do you need an interpreter when dealing with us? 9 Your name

This includes an interpreter for people who have a hearing or Mr Mrs Miss Ms Other
speech impairment.
Family name
No Go to 4
Yes Go to next question
First given name
2 What is your preferred spoken language?
Second given name

3 What is your preferred written language?

10 Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
4 Are you a full-time student? No Go to next question
No You will not be entitled to this Health Care Card. Yes Give details below
Go to humanservices.gov.au/paymentfinder
1 Other name
Yes Go to next question

5 On the day before you turned 16 years, was your parent/carer

in receipt of a Carer Allowance Health Care Card on your behalf?
Type of name (e.g. name at birth)
No You will not be entitled to this Health Care Card.
Go to humanservices.gov.au/paymentfinder
Yes Go to next question
2 Other name
6 Give details below of the parent/carer who received a Carer
Allowance Health Care Card on your behalf?
Family name
Type of name (e.g. maiden name)

First given name

If you have more than 2 other names, attach a separate sheet
with details.
Second given name

11 Your gender
Male
7 Parent/Carer’s date of birth Female

/ /
12 Your date of birth
/ /
8 Parent/Carer’s Centrelink Reference Number (if known)

CLK0SS456 1707

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13 Your permanent address 17 Please read this before answering the following question.
This question is voluntary and will not affect your payment.
If you do answer, the information will help us to continue
to improve services to Aboriginal and Torres Strait Islander
Australians.
Postcode
Are you of Aboriginal or Torres Strait Islander Australian descent?
If you are of both Aboriginal and Torres Strait Islander Australian
14 Your postal address (if different to above) descent, please tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
Postcode
18 Please read this before answering the following question.
15 Please read this before answering the following question. This question is voluntary and will not affect your payment.
If you do answer, the information will help us to continue to
If you provide an email address or mobile phone number, you improve services to people of Australian South Sea Islander
may receive electronic messages (SMS or email) from us. descent.
To read the Terms and Conditions, go to
humanservices.gov.au/em or visit one of our service centres. Australian South Sea Islanders are the descendants of
Pacific Islander labourers brought from the Western Pacific
Your contact details in the 19th Century.
Home phone number ( ) Are you of Australian South Sea Islander descent?
Is this a silent number? No Yes No
Yes
Mobile phone number
Is this a silent number? No Yes 19 Do you want to authorise another person or organisation to
make enquires, get payments and/or act on your behalf?
Fax number ( )
No Go to next question
Work phone number ( ) Yes You will need to complete and attach an
Authorising a person or organisation to
Alternative phone number ( ) enquire or act on your behalf form (SS313).
If you do not have this form or want more
Email information about nominee arrangements,
go to humanservices.gov.au/nominees

@
20 What country are you currently living in?
The country of residence is where you normally live on a
16 Your student details long term basis.
Education institution/course
Name of school/ Australian Technical College/campus Australia Go to next question
Other Country of residence

Your student identification number

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21 Have you EVER travelled outside Australia, including short trips 27 Your visa details on arrival
and holidays? Visa sub class Date visa granted
This question assists us to verify your Australian residence. / /
No Go to next question
Not applicable – Never Go to next question 28 Has your visa changed since you arrived in Australia?
travelled to Australia No Go to next question
Yes Give details below
Yes Most recent visa details
Year you last entered Australia Visa sub class Date visa granted
/ /
Passport number

29 When did you most recently start living in Australia?

Country of issue / /

30 Are you a refugee or former refugee?

22 Are you an Australian citizen who was born in Australia? No
No You will need to provide proof of your Yes
Australian residence status (e.g. citizenship
papers, passport or other documentation)
31 Did your partner or either of your parents arrive on a refugee or
Go to next question humanitarian visa?
Yes Do not answer questions 23 to 31. No
Go to 32 Yes

23 What is your country of birth?

24 What is your country of citizenship?

Australia Date granted
/ / Go to 32
Other Give details below
Country of citizenship

Date granted
/ /

25 Have you ever lived in Australia?

No Go to 33
Yes Go to next question

26 What type of visa did you arrive on?

New Zealand passport Go to 28
(Special Category visa)
Permanent Go to next question
Temporary Go to next question
Unknown (e.g. arrived Go to 28
on parent’s passport)

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32 Please read this before answering the following question. 33 Which of the following forms, documents and other attachments
We need to know if you have lived in any countries other than are you providing with this form?
Australia. ‘Lived’ means where you or your family made your If you are not sure, check the question to see if you should attach
home or spent a long period of time – it does not include the documents.
places you visited for a holiday.
Where you are asked to provide documents, please attach
Have you EVER lived outside Australia for any period? original documents.
No Go to next question Confirmation of identity
Yes List ALL countries you have lived in since birth and (Refer to page 2 for more information)
the date you started living in each country. Authorising a person or organisation to enquire or act
Include when you started living in AUSTRALIA. on your behalf form (SS313)
Do NOT include short trips or holidays. (if you answered Yes at question 19)
Proof of your Australian residence status
1 Country of residence (if you answered No at question 22)

/ / / /
34 IMPORTANT INFORMATION
From To
Privacy and your personal information
2 Country of residence Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
From / / To / / information is required to process your application or claim.
Your information may be used by the department, or given
3 Country of residence to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
You can get more information about the way in which the
From / / To / / department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
4 Country of residence
35 Statement
I declare that:
From / / To / / • the information I have provided in this form is complete
and correct.
5 Country of residence I understand that:
• giving false or misleading information is a serious offence.
• I must return all supporting documents at the same time as
/ / / / I lodge my claim form. If I do not return all documents, my
From To claim may not be accepted. The only exception will be if I
am waiting for medical evidence or other documents from a
6 Country of residence third party.
• I must tell the Australian Government Department of Human
Services of any changes to this information within 14 days.
• the Australian Government Department of Human Services
From / / To / / can make relevant enquiries to make sure I receive the
correct entitlements.
If you need more space, attach a separate sheet with details.
Your signature

On completion of this form,

please print and sign by hand

Date
/ /

Print Clear
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