, authorise:
• the Department of State Growth (the department) to use Centrelink Conrmation eServices to perform a Centrelink
or Department of Veterans’ Affairs enquiry of my Centrelink or Department of Veterans’ Affairs customer details and
concession card status to enable the department to determine if I qualify for a concession, rebate or service, and
• Services Australia (the agency) to provide the results of that enquiry to the department.
I understand that:
• The agency will disclose personal information to the department including my name, address, payment type, payment status,
number of dependent children, and concession card type and status, to conrm my eligibility for the Transport Access
Scheme.
• This consent, once signed, remains valid while I am a customer of the department unless I withdraw it by contacting the
department or the agency. I can get proof of my circumstances or details from the agency and provide it to the department so
my eligibility for the Transport Access Scheme can be determined.
• If I withdraw my consent or do not alternatively provide proof of my circumstances or details, I may not be eligible for the
Transport Access Scheme provided by the department.
I authorise my doctor or qualied health care practitioner to provide all medical information required in the assessment of my
application for membership of the Transport Access Scheme.
I have informed the doctor of all relevant illnesses and consent to the medical information provided with this application to be shared
with the Registrar of Motor Vehicles in relation to my eligibility to hold a driver licence under the Vehicle and Trafc Act 1999.
I consent to the Registrar of Motor Vehicles contacting any reporting health professional named in this application for further
information.
I understand if the Registrar of Motor Vehicles cancels or suspends my driver licence on the basis of this medical report, I may be
re-licensed when I provide evidence that I meet the national medical standards. If this application is approved I acknowledge that
misuse of any concession or subsidies provided may lead to suspension or cancellation of membership and could result in legal action
being taken by the Department of State Growth. I conrm the information in this application is true and correct.
You are providing personal information to the Department of State Growth, which will manage that information in accordance with the
Personal Information Protection Act 2004.
The personal information collected here will be used by the Department, and may be disclosed to other authorities including the Registrar of Motor
Vehicles, Services Australia, the Department of Premier and Cabinet, the National Disability Insurance Agency and the Transport Commission, for
the purpose of assessing initial and ongoing eligibility for the Transport Access Scheme, registration and licensing concessions, assessing medical
tness to drive, and cross-checking eligibility against other schemes.
Failure to provide this information may result in your application not being processed or records not being properly maintained. The Department may
disclose information you provide to third parties to facilitate the Scheme or under other circumstances allowed for by law. You have the right to ask
the Department to give you access to the personal information you have provided. You may be charged a fee for this service.
If your application is approved, further personal information may be collected in relation to the scheme, and this will be managed in accordance with
the Personal Information Protection Act 2004. The Department also collects trip information for every taxi trip where a subsidy is claimed using a Taxi
Subsidy Smartcard. This information may be disclosed to other authorities including the Department of Premier and Cabinet, the National Disability
Insurance Agency, the Transport Commission, and law and enforcement authorities.
Signature of applicant (or signature of applicant’s authorised person*) Date signed
I
Personal Information Protection Statement
Part Two: Concession Card Details
Centrelink - Health Care Card
Centrelink - Pensioner Concession Card
Centrelink - Commonwealth Seniors Health Card
Department of Veterans’ Affairs - Pensioner Concession Card
Department of Veterans’ Affairs - Commonwealth
Seniors Health Card
CRN
-
-
-
DVA le numberOR
Provide your Centrelink CRN or DVA le number
Select your concession card type
- tick the applicable box
Part Three: Consent and Declaration
This section can only be signed by the applicant or their authorised person, an applicant’s advocate cannot sign on behalf of the applicant.
See attached Transport Access Scheme Information for accepted authorised persons.
Complete this section if you are applying for the Taxi Subsidy Program and are not reliant on a wheelchair.
If the applicant is under the age of 16, a photocopy of both sides of their concession card MUST be attached to the application.
*If authorised person signing on behalf of the applicant, evidence of authorisation must be attached.