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).

You must download our forms and fill them in so they are processed quickly. You can also electronically sign some of our forms. We have help available if you use assistive technology.

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.

Page last updated: 17 November 2022.
QC 52650