Medicare Compensation Recovery Section 23A Statement form (MO023)

Use this form to declare you received no benefits; or received no further benefits since your most recent expired notice, for your compensable injury or illness.

The injured person (or claimant) may give this statement to us only if declaring that a Notice of past benefits has never been issued in relation to the case for compensation or a Notice of past benefits has previously been issued, but had expired at the time of judgment or settlement.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

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Page last updated: 27 August 2017