Relationship between housekeeping and food and beverage

1 of 2Si039.1407Your nameOtherFamily name1First given nameSecond given nameMsMissMrsMrYour Centrelink Reference Number (if known)4Authority to ReleasePersonal Information – Personal Injury,Insurance, Superannuation or Other MatterPurpose of this formThis form is used to obtain your consent for the Australian GovernmentDepartment of Human Services to provide certain information aboutyou, regarding Centrelink payments and services, to a law firm, aninsurance company, a superannuation fund, another government agencyor other third party organisation, where the information sought can bedisclosed under our administrative access scheme.Under our administrative access scheme, we will provide Centrelinkpayment tax summary information (some payments may not be included),earnings information, medical certificate information and medical, JobCapacity Assessment and Employment Services Assessment reports(and/or other specific information), or a combination of these items,for certain periods, as specified on this form.Not all your personal information may be released under this scheme.Some information may need to be considered formally under otherlegislation. We will advise the third party if this is required.Your personal information is disclosed in accordance with the generalconsent provisions contained in social security law.This form should not be used if you need compensation recovery advice.For more information, go to our websitewww.humanservices.gov.au/centrelinkcompensationrecoveryFilling 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 questionnumber shown. You do not need to answer the questions inbetween.Returning your form(s)Check that you have answered all the questions you need to answerand that you have signed and dated this form. Forms that are incompletemay not be processed.Return this form to the third party indicated at question 7.The third party should fax this completed form to the InformationRelease Team on 1300 080 619. Alternatively, this form can be scannedand emailed to tpo.consent@humanservices.gov.auYour date of birth3/ /Your postal address5PostcodeHave 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)?2NoYe sGo to next questionGive details of other name(s)If you require more space, attach a separate sheetwith details.Have you ever claimed or received a Centrelink payment orservice?6NoYe sGo to next questionGive details belowddmmyyyyCLK0Si039 1407
2 of 2Details of the third party organisation (i.e. who is requesting yourinformation and where your information is to be sent).7NameAddressPostcodeThird party reference number (if known)Si039.1407See Page 1 for instructions on returning this form.Privacy and your personal informationYour personal information is protected by law, including thePrivacy Act 1988, and is collected by the AustralianGovernment Department of Human Services for theassessment and administration of payments and services. Thisinformation is required to process your application or claim.Your information may be used by the department or given toother parties for the purposes of research, investigation orwhere you have agreed or it is required or authorised by law.You can get more information about the way in which theDepartment of Human Services will manage your personalinformation, including our privacy policy atwww.humanservices.gov.au/privacy or by requesting a copy fromthe department.9IMPORTANT INFORMATIONDeclaration or Authorisation by another personIf the person cannot consent to the release of their own personalinformation (e.g. they are a child, they have a Power of Attorneyor they are deceased), and another person can authorise therelease, complete the following:10Reason for authorisation by another personPosition heldPrint nameNote: If you are authorising the release of a deceased person’sinformation, there may be limits to who can authorise therelease (i.e. the Executor) and what can be released under thisadministrative access scheme. Proof will also be required.Your signatureDate/ /StatementI declare that:• the information I have provided on this form is complete andcorrect.• I give my consent for the Australian Government Departmentof Human Services to provide the personal information asauthorised on this form, to the third party indicated atquestion 7.I understand that:• this authority remains valid for a period of 12 months fromthe date it is signed and dated, unless revoked by mebeforehand.Type and amount of Centrelink payments (some paymentsmay not be included)8Select and complete each item you are consenting to release.Note: The release of this information is not compensation advice./ /from/ /toDetails of earnings from employment for the period/ /from/ /toMedical certificate information, medical, Job CapacityAssessment and Employment Services Assessment reports/ /from/ /toOther – Give details belowfor the period by FortnightFinancial yearOR