Fill - Free fillable Fair Deal Application Form 02911 HSE NHSS Proof#06 Final Application.indd (Ireland

Nursing Homes Support Scheme

Information and Application Form

Use this form to apply for the Nursing Homes Support Scheme. Completed forms should be returned to your HSE

Nursing Homes Support Ofﬁ ce, who can also provide help to complete your application. Contact details for HSE

Nursing Homes Support Ofﬁ ces are on the back page of this form. Before completing this form, you can read more

detailed information on this scheme in the Nursing Homes Support Scheme Information Booklet.

n What is the Nursing Homes Support Scheme?

The Nursing Homes Support Scheme provides ﬁ nancial support towards the cost of long-term nursing home care.

Under the scheme, people who need nursing home care have their income and assets assessed, and then make a

contribution towards the cost of their care based on their assessment. The HSE will pay the rest, if any, of the costs of

their care in designated public and approved private nursing homes covered under the scheme. People can choose

care in any of the nursing homes included in the scheme provided that the nursing home can cater for the person’s

particular needs and that it has a place available for the person. As the budget for this scheme is ﬁ xed each year, at

times a waiting list for ﬁ nancial support may be in place.

n Who can apply for the scheme?

Anyone who may need long-term nursing home care can apply. You must be ordinarily resident in the State, which

means that you have been living here for at least 1 year or you intend to live here for at least 1 year.

n How does the application process work?

There are 2 parts to the application process: a Care Needs Assessment and a Financial Assessment. The Care Needs

Assessment is carried out by healthcare staff e.g. Doctors, Nurses, Social Workers, and looks at your healthcare needs

and your family and social supports. The outcome will show if you need long-term nursing home care.

If the Care Needs Assessment shows that you need long-term nursing home care, the Financial Assessment will work

out the amount that you will pay towards the cost of your care and the amount that the HSE will pay. The amount that

you pay for your care depends on your income and the value of your assets. People who have less income/assets pay

less and people who have more income/assets pay more. No-one will pay more than the cost of their care.

n What ﬁ nancial support does the HSE offer?

There are two types of ﬁ nancial support available under this scheme; State Support and a Nursing Home Loan

(Ancillary State Support).

State Support: Your income and assets are assessed and your weekly contribution is worked out. The HSE will pay

the rest of the weekly cost of your care, this is called State Support.

Nursing Home Loan (Ancillary State Support): This is an optional extra feature of the Nursing Homes Support

Scheme for people who own property/land based assets in the State. Instead of paying your full weekly contribution

for your care from your own means, you can choose to apply for a Nursing Home Loan, to cover the portion of your

contribution which is based on property/land based assets within the State. The HSE will then pay that portion of your

cost of care on top of your State Support payment.

The loan is paid back to the State after the sale of all or part of the asset or your death, whichever occurs ﬁ rst.

Repayment of the loan is made to the Revenue Commissioners. In certain cases, repayment of the loan can be

deferred, and you can read more about this in the Information Booklet. This part of the scheme is designed to protect

people from having to sell their home during their lifetime to pay for nursing home care.

n Do I pay the same contribution for as long as I am in nursing home care?

If you are approved for ﬁ nancial support under the scheme, you will pay the same contribution provided that your

circumstances remain the same. The HSE can review, either at your request or on its own initiative your care needs,

ﬁ nancial assessment or the amount of the nursing home loan. You can read more about this in the information booklet.

n If my circumstances change?

You must advise the HSE within 10 working days if you or your partner’s circumstances change, as your ﬁ nancial

support may be affected e.g. if your spouse/partner dies or you or your spouse/partner sell your property. Failure to

advise the HSE may result in an overpayment of State support which must be repaid to the HSE. If a person does not

notify the HSE of a change in circumstances, he/she is guilty of an offence and is liable for a summary conviction to a

ﬁ ne not exceeding €1,000.

Form NHSS1

Version No. 03/17

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Have you or your partner (living or deceased) previously applied for State Support or Subvention?

Yes

If yes, when (if known)

Relationship Status – Please choose only one of the following:

Couple

Tick

You are married and living together/co-habiting

If co-habiting, please state the number of years you have been co-habiting with your partner

Years

Single

Tick

Not married/Not living as part of a couple/Share a home with another adult, e.g. a sibling or a friend

Widow/er

Tick

If “yes” please include copy Death Certiﬁ cate of spouse if applying for the nursing home loan under Part 6A

Separated/

Divorced

Tick

You were married but are now separated or divorced and living apart from your former spouse

Do you currently hold a Medical Card, GP Visit Card, Hepatitis C HAA Card, Long Term

Illness Card or a Drugs Payment Scheme Card?

Yes

Please supply the Number (if known)

n Do you assess a couple’s income jointly?

People not living as part of a couple are assessed singly, and people who are living together as part of couple are

assessed jointly. A couple includes:

n Married couples living together

n Co-habiting couples (living together for 3 years or more)

n Same sex couples (living together for 3 years or more)

It does not include siblings who live together, or two adults living together but not as life partners. Where a member of

a couple is applying for the nursing home loan, their spouse or partner must sign that part of the application.

n Who should ﬁ ll in this form?

The form should be completed by and must be signed by the person applying for nursing home care. Help and advice

is available from health care workers and from the HSE Nursing Homes Support Ofﬁ ces. If a person applying for nursing

home care has reduced ability to make decisions, a speciﬁ ed person can apply for State Support on their behalf. If the

person has reduced ability to make decisions and is applying for the Nursing Home Loan, a Care Representative must

make the application. A person appointed under Enduring Power of Attorney or the Committee of a Ward of Court can

also make an application in such circumstances. You can read more about this in the Information Booklet.

n What do I need to include with my application form?

Your application must include documentary evidence to support any information you have provided. Details of what is

required are given in each section.

Part 1A – Applicant’s Details – Please use BLOCK CAPITALS

(The applicant is the person who may need care)

Surname:

Are you ordinarily resident in Ireland? Yes No

First Name(s):

Have you ever lived abroad? Yes No

Date of Birth:

D D M M

Y Y Y Y Home Address: (Please include post code)

Daytime Phone:

Gender:

Male

Female

PPS Number

(mandatory):

Current address if different from home address:

(living with relative, or in hospital/nursing home)

E-mail address:

Birth surname:

(If different from above)

Town:

If in hospital/nursing home please

state date of admission:

County:

OFFICE USE ONLY

Nursing Homes Support Scheme Application Form Date Received

_ _ _ _

Ref No.

_ _ _ _ _

Nursing Homes Support Scheme Application Form

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Please provide details of your legal representative/solicitor if known

Tel No.:

We understand that you may wish to have some help or support from a relative or friend in making this

application and gathering documentation. If you do, please provide contact details for this person here:

Name:

Address: Relationship to Applicant:

Tel No.: Mobile No.:

Please note that in nominating a contact person you consent to that person receiving copies of

documentation on your care needs and ﬁ nancial assessments.

Part 2 – Application for Care Needs Assessment

Part 2 A – To be completed by a person who may need care services.

I, __________________________________________________ hereby apply for a Care Needs Assessment

under the Nursing Homes Support Scheme.

Signed:

Part 2 B – To be completed where a person is unable to make application for Care Needs

Assessment on their own behalf.

I, _________________________________________________ hereby apply for a Care Needs Assessment under

the Nursing Homes Support Scheme on behalf of ___________________________________________________

who it appears may need care services and is unable to make application on his/her own behalf by reason of

ill-health, physical disability or a mental condition.

I make this application as: (Tick correct box)

(a) spouse/partner;

(f) registered social worker;

(b) a relative over 18 years of age;

(g) Committee of Ward of Court*;

(h) next friend appointed by the Court*;

(d) registered medical practitioner;

(i) Attorney under Enduring Power of Attorney*;

(e) registered nurse;

(j) Care Representative appointed by the Court*

Signed:

Address: ___________________________________________________________________________________

____________________________________________________________________________________________

Tel: _________________________________________ Email: _________________________________________

(* Please enclose documentary evidence)

Dated:

D D / M M /

Y Y Y Y

Dated:

D D / M M /

Y Y Y Y

Nursing Homes Support Scheme Application Form

Spouse/Partner’s Full Name: PPSN: (mandatory) Date of Birth: (mandatory)

If you are a member of a couple, is your spouse/partner in long term care?

If yes, please provide the following information:

Yes

Name of Residential/Nursing Home: Weekly Contribution for Care: €

Type of Care:

NHSS

Public NH Private NH Contract Bed Subvention Other

Please specify

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Part 3A – Details of income

If you are part of a couple please supply details for your spouse/partner. Please include

documentary evidence of all income, e.g. pension payslip. Net Weekly Income should be

provided, i.e. your weekly income after Tax, PRSI etc. have been deducted.

Nursing Homes Support Scheme Application Form

Amount per week

Income

Applicant Spouse/Partner

Department of Social Protection pension/allowance/beneﬁ t

€ €

Any other non-Irish pension

€ €

Occupational pension

Please include a copy of your pension slip

€ €

Employment, trade, profession or vocation (including for part time work)

Please include a copy of a pay slip, P60 or P21

€ €

Income from rentals (in the State or otherwise)

€ €

Income from holding an ofﬁ ce or directorship

€ €

Income from fees, commissions, dividends, interest, or income

of a similar nature

€ €

Payments under a settlement, covenant, estate or a payment in respect

of maintenance

€ €

Income from royalties and annuities

€ €

Income that was transferred from you to another person within the last

5 years

€ €

Farming/Business Income If income arises from a Farm or Business

please attach tax assessment from Revenue, accounts in respect of

same for the previous tax year and details of any Department of Agriculture

payments

€ €

Any other income:

€ €

Please supply Applicant Spouse/Partner

PPS number

(mandatory)

Department of Social Protection Pension book number

Department of Social Protection Pension claim number

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Part 3B – Allowable Deductions

Some expenses may be deducted from your income for this assessment. Please give

details of allowable deductions.

Savings, Deposits and Current Accounts (please give a total amount) Applicant Spouse/Partner

Bank

€ €

Credit Union

€ €

Post Ofﬁ ce

€ €

Other (please specify)

€ €

Stocks, shares, bonds, securities etc.

€ €

Money loaned to another person which is repayable

€ €

Total Cash Assets transferred to another person within the last 5 years

(cash, savings/deposits, shares, bonds, securities etc.)

€ €

If any of the transferred assets have been returned, please state the total amount returned

€ €

Other Cash Assets

€ €

Amount per year

Applicant Spouse/Partner

Health Expenses (e.g. doctors’ fees, pharmacy costs, prescription charges)

€ €

Interest on loans related to your principal residence

€ €

Rent Payments (If you live in rented accommodation)

€ €

Maintenance Payments to another person

€ €

Levies required by law to be paid e.g. property tax

€ €

Amounts above should be provided annually, net of Tax Relief.

The HSE will require evidence of these deductions during your assessment.

Borrowings in respect of your principal residence

(where you choose to avail of this deduction, you cannot

offset the same borrowings against the value of the asset)

€ €

Please provide documentary evidence of borrowings.

Part 4A – Details of Cash Assets

Please give details of all Cash Assets, giving the total balance amounts for you and your

spouse or partner. Please provide documentary evidence of cash assets e.g. recent bank

statements.

Nursing Homes Support Scheme Application Form

Do you wish to claim an allowable deduction in respect of a dependent child/children who

is/are under 21 or in full time education

Yes

Please provide veriﬁ cation on your dependant’s name(s), date(s) of birth and full time education status

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Part 4B – Details of Non-Cash Assets

Non-Cash Assets means all forms of property, land or valuables owned by you and your

spouse or partner, whether within the State or outside. Please include documentary

evidence of assets, values and any outstanding balances on loans.

Principal Residence

Home Address

Please indicate if you are the owner/joint owner/tenant/lodger/local

authority tenant purchaser/other (please specify)

If you own or partly own your property please provide current

market value of your home. (Please furnish a Certiﬁ cate of Market

Value from an Auctioneer or a Valuer)

€

Monthly Loan

Repayment

Outstanding

Balance on Loan

Indicate loan repayments (amount per month) and outstanding

balance on same (Include latest available statement of loan)

€ €

Please Specify loan type of outstanding balance

i.e. Mortgage, Life Loan, Credit Union, Other

Transferred Assets

Please supply details of any non-cash assets (property/land) sold or transferred to another person in the last 5 years.

Asset Details Date of

Transfer

Value at time

of Sale or Transfer €

Amount Received

from Sale/Transfer €

If transferred,

to whom?

Please supply documentary evidence of the amount received or the market value of asset at the time of sale/transfer

Other Non-Cash Assets (property, land, farm, business etc.)

Please provide details (including address if appropriate)

Value in € for

applicant and

spouse

Outstanding

Balance on Loan

€ €

Please furnish a Certiﬁ cate of Market Value from an Auctioneer or a Valuer.

Please supply details of any mortgage or charge on the Non-Cash Assets listed above.

Nursing Homes Support Scheme Application Form

Please note that if a person knowingly gives false or misleading information in connection with an application for State

support, he/she is guilty of an offence and is liable on summary conviction to a ﬁ ne not exceeding €5,000 or imprisonment

for a term not exceeding 3 months or both. In cases where a person does not disclose or makes a misstatement in

respect of the amount or value of income/assets and receives a greater amount of State support than would have been

the case if there had been disclosure or no misstatement, the overpayment must be repaid by the person on demand and

may be recovered by the HSE as a simple contract debt from the person or estate of that person.

Please note that the personal representative of a deceased person is legally obliged as soon as practical but in any case

not less than 3 months before any distribution of assets of the estate of the person give the HSE (a) a schedule of assets

that is applicable to the estate of the deceased person and (b) notice in writing of the representatives intention to distribute

the assets. A Personal Representative who does not retain sufﬁ cient assets of the estate to repay any amount due and

payable to the HSE will be held personally liable for that amount.

02911-HSE-NHSS-Proof#06-Final-Application.indd 6 06/03/2017 11:18

Part 5 – Application for State Support

Please read the following and then sign either Part 5A or 5B as appropriate

As part of this application, the HSE will make arrangements for a Care Needs Assessment and a Financial

Assessment to be carried out. Any organisation with information relevant to the applicant’s care needs may

provide the HSE with this information. The content of the care needs assessment report may be provided to,

or shared with, relevant health professionals, if required. All required information which the HSE may request

in connection with the consideration of this application will be provided. To process this application the HSE

may seek limited access to social welfare data to conﬁ rm details of the applicant, their spouse/partner and

dependants. The signature below indicates consent to this access. The HSE will treat all information and

personal data provided to them as conﬁ dential. The HSE will only disclose information or personal data to

other people or bodies according to law. The applicant must report to the HSE, within 10 working days,

any changes in his/her or their partner’s circumstances which may affect entitlement to ﬁ nancial support.

Part 5A To be completed by the person who needs care services:

I hereby apply for State Support under the Nursing Homes Support Scheme. I have read Part 5 above and

I say that the information given by me on this form is correct to the best of my knowledge and belief.

Signed:

Part 5B To be completed only where the person who may need care services has reduced capacity

to make decisions and is unable to make the application

I, ________________________________________________________ hereby apply for State Support under the

Nursing Homes Support Scheme on behalf of ______________________________________________________

(persons name)

I make this application as: (Tick correct box)

(a) Committee of Ward of Court**

(b) Attorney under Enduring Power of Attorney**

(d) spouse/partner;

(e) a relative over 18 years of age;

(f) next friend appointed by the Court**;

(g) legal representative;

(h) registered medical practitioner;

(i) registered nurse;

(j) registered social worker;

Categories (a) to (c) above have priority over those at (d) to (j). Please refer to the Information Booklet for further

information.

I have read Part 5 above and I say that the information given by me on this form is correct to the best of my

knowledge and belief. No person has priority to make this application before me / All persons with higher

priority have consented in writing (copy/copies attached) to my making this application (delete as applicable).

(See Information Booklet)

Signed:

(** Please enclose documentary evidence)

Dated:

D D / M M /

Y Y Y Y

Dated:

D D / M M /

Y Y Y Y

Nursing Homes Support Scheme Application Form

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Part 6 – Nursing Home Loan (Ancillary State Support)

The Nursing Home Loan (Ancillary State Support) is an additional support designed to

ensure that people do not have to sell assets such as their home during their lifetime

in order to meet their care costs.

This is an optional extra feature of the Nursing Homes Support Scheme for people who own property/land based assets in the

State. It is a loan advanced by the HSE to you. It is paid to help you meet the portion of your contribution to the cost of care that

is based on Irish property/land based assets (i.e. land and property within the Irish State).

Payment of the Nursing Home Loan (Ancillary State Support) by the HSE results in the creation of a charge (a simple type of

mortgage) in favour of the HSE against the interest of the applicant and his/her partner in the asset(s) set out in this application. The

HSE will notify the Property Registration Authority of the charge who will register it against the asset(s) speciﬁ ed in this application.

You may therefore wish to seek independent legal advice before you apply for a Nursing Home Loan (Ancillary State Support).

However, please note that there is no requirement on you to do so.

Where the home, farm, business or other asset is owned by more than one person, the HSE requests all joint owners to ﬁ ll in Part

6B of this form.

The Nursing Home Loan (Ancillary State Support) may be applied for at any time, not just when entering into long-term nursing

home care. Applications for the Nursing Home Loan may be granted by the HSE subject to the overall budget available to it.

The Nursing Home Loan (Ancillary State Support) together with interest is repayable (unless the applicant has voluntarily repaid

the loan prior to it falling due for repayment)

(a) when the applicant dies, or

(b) when any part of the charged asset is transferred/sold (HSE must be notiﬁ ed within 10 working days of transfer/sale) or

(d) if the HSE determines that it has been given false/misleading information relating to this loan application

Repayment of the loan must be made to the Revenue Commissioners [see below]

The following provides information on how the process works:

The person who is responsible for repayment of the nursing home loan to the Revenue Commissioners is called the “relevant

accountable person”. The relevant accountable person may be a different person to the applicant, depending on the

circumstances as set out in the following examples:

Example 1: Where you transfer or sell part or all of your property, during your lifetime, you and your spouse/partner will be the

relevant accountable persons.

Example 2: Where the loan is repayable after the applicant’s death the personal representative of the deceased is the relevant

accountable person. A person who inherits or has an interest in the property or any part of it can also be held accountable for

repayment of the loan.

When the repayment must take place

When the nursing home loan falls due for repayment, the HSE writes to the relevant accountable person. The HSE notiﬁ es him/her

that the loan must be repaid and advises of the amount due. In calculating the amount due the HSE applies the consumer price

index to the loan to take account of inﬂ ation or deﬂ ation since the loan was paid.

Repayment timeframes

The following timeframes apply for repayment of the nursing home loan;

n Where the repayment arises, for example, because of the death of the person in care the loan must be repaid within 12

months of the date of death. Where the repayment is not made within this timeframe, Revenue will apply interest on

the amount owing from the date of death.

n Where the loan is repayable because of the sale or transfer of your property during your lifetime, it must be repaid within 6

months of the date of sale/transfer or Revenue will apply interest back to date of sale/transfer.

How the repayment is made

Revenue Commissioners are the collecting agent for the HSE in respect of monies advanced by way of a nursing home loan. The

Nursing Home Loan must be repaid to Revenue. It should be repaid as soon as possible after notice is received from the HSE

and, in any event, within the timeframes outlined above. Further information is available on how to make payments on Revenue’s

website at www.revenue.ie

Deferral of Repayment of Nursing Home Loan

Where the loan becomes repayable on death, the repayment of monies based on the principal residence can be deferred in

certain cases. You can read more about this in the information booklet.

In relation to deferrals, the following timeframes apply for repayment of the nursing home loan:

n On the death of the partner of the person who was in receipt of care or on the death of the connected person, the loan must

be repaid within 12 months of the date of death of that person. For more information on the deﬁ nition of a connected person

please see the information booklet.

n Where a person ceases to be a connected person as deﬁ ned in the legislation or where an interest in the residence is

transferred/sold, the loan must be repaid within 6 months of the date the person ceased to be a connected person or date of

the transfer/sale.

Nursing Homes Support Scheme Application Form

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Signed:

(Applicant)

Signed:

(Partner/Spouse)

Signed:

(Representative of Applicant)

Signed:

(Representative of Partner)

If you are signing as a representative, please provide evidence of your appointment as a Care

Representative/Attorney under Enduring Power of Attorney/Committee of a Ward of Court.

Name(s) of any other person(s) residing at the applicant’s principal residence at date of application

Number of years residing at applicant’s principal residence

Relevant Accountable Person (See Explanatory Note on Page 8)

Name:

Address:

Tel No.: Mobile No.:

PPSN:

The Revenue Commissioners require the above details of the Relevant Accountable Person for the repayment

of the nursing home loan.

A person who knowingly or recklessly gives the HSE information which is false or misleading in connection

with an application for ﬁ nancial support is liable on conviction to a ﬁ ne and/or imprisonment.

Part 6A – Application for a Nursing Home Loan

(Ancillary State Support)

I/We hereby apply for and request payment of the Ancillary State Support (Nursing Home Loan) under the

Nursing Homes Support Scheme Act, 2009 (“the Act”) in respect of the following property/land based asset(s)

within the State. I/We acknowledge that payment of Ancillary State Support results in the creation of a Charge

in favour of the Health Service Executive (which by virtue of the Act is deemed to be a mortgage made by

deed) against the interest of the person to whom payment relates and of the partner of that person in such

land as is speciﬁ ed in the request for payment of the Ancillary State Support (Nursing Home Loan). I/We

consent to the creation of a Charge in favour of the Health Service Executive over the asset(s) listed below.

1st Property 2nd Property

Details of Asset: Details of Asset:

House No./Name: House No./Name:

Street: Street:

Town/City: Town/City:

Townland: Townland:

County: County:

Folio Number (if known): Folio Number (if known):

(Please provide documentary evidence of the title to the property, e.g. copy land registry Folio/copy Title Deeds/

copy lease/copy conveyance. If the property is leasehold a copy of the lease must be provided)

Dated:

D D / M M /

Y Y Y Y

PPSN:

Dated:

D D / M M /

Y Y Y Y

PPSN:

Dated:

D D / M M /

Y Y Y Y

PPSN:

Dated:

D D / M M /

Y Y Y Y

PPSN:

Nursing Homes Support Scheme Application Form

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Part 6B – Consent of Joint Owner(s)

Any person(s) who jointly owns a property with the applicant is requested to sign this section.

I/we __________________________________ and __________________________________ , (the joint owner(s)

of the asset(s) listed below), hereby give my/our prior written consent to the creation of a Charge in favour of

HSE under the Nursing Homes Support Scheme Act, 2009 (“the Act”) in respect of the following property/

land based asset(s) within the State. I/we acknowledge that payment of Ancillary State Support results in

the creation of a Charge in favour of the Health Service Executive (which by virtue of the Act is deemed to

be a mortgage made by deed) against the interest of the person to whom payment relates and of the partner

of that person in such land as is speciﬁ ed in this request for payment of Ancillary State Support.

1st Property 2nd Property

Details of Asset: Details of Asset:

House No./Name: House No./Name:

Street: Street:

Town/City: Town/City:

Townland: Townland:

County: County:

Folio Number (if known): Folio Number (if known):

Signed:

(Joint Owner)

Signed:

(Joint Owner)

The absence of prior consent in writing of a joint owner does not render void the making of a

Charge in favour of the HSE.

Dated:

D D / M M /

Y Y Y Y

Dated:

D D / M M /

Y Y Y Y

Nursing Homes Support Scheme Application Form

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Checklist

Where documentary evidence is being sent with this application, photocopies are

acceptable – you do not need to send original documents

Have you provided proof of income from

n Department of Social Protection pension/allowance/beneﬁ t

n Occupational Pension – recent payslip, P60 or P21

n Non-Irish pension

n Employment trade, profession or vocation

n Rentals – in the state or otherwise

n Holding an Ofﬁ ce or Directorship

n Fees, commissions, dividends, interest or income of a similar nature

n Payments under a settlement, covenant, estate or a payment in respect of maintenance

n Royalties and annuities

n Transferred income

n Farming/business – please attach tax assessment from Revenue and accounts in respect of

previous year

n Any other income

Have you provided details of Cash Assets?

n Savings and Deposits – please provide copies of full statements from banks, credit union, post ofﬁ ce etc.

n Stocks, Shares, Bonds, Securities and other ﬁ nancial instruments – please provide statements of value

n Money loaned by you to another person which is repayable – please provide details

n Details of any cash assets transferred in the past ﬁ ve years

n Details of any other cash assets

Have you provided details of Non-Cash Assets – Property and Land?

n If you own your home provide details of current valuation

n Details and valuations of interest in other houses/land/business in the State

n Details and valuations of interest in overseas houses/land/business

n Details of any non-cash assets transferred in the past ﬁ ve years

n Details of any other non-cash assets

n Details of any mortgage or charge on Non-Cash Assets

Have you provided information if applying for a Nursing Home Loan (Ancillary State Support)?

n Details of Property and Folio Numbers – if known

n Have you considered taking independent legal advice?

n Name and PPSN of Accountable Person

Additional Information

n You must provide your Personal Public Services Number (PPSN) in Part 1A

n Have you signed the application for Care Needs Assessment in Part 2?

n Have you signed the application for State Support at Part 5?

n If you are applying for the Nursing Home Loan, have you read and signed Part 6?

n If you are applying on behalf of another person, have you provided the requested details of your

entitlement to do so?

n If you are currently in a nursing home/hospital please supply a letter stating date of admission.

Nursing Homes Support Scheme Application Form

02911-HSE-NHSS-Proof#06-Final-Application.indd 11 06/03/2017 11:18

HSE Nursing Homes Support Ofﬁ ces

Your Nursing Homes Support Ofﬁ ce is available to help you ﬁ ll in the form or answer questions

about your application. When you have completed this form, send it to the Nursing Homes

Support Ofﬁ ce for your area:

Carlow/Kilkenny HSE Nursing Homes Support Ofﬁ ce, Community Services,

James’s Green, Kilkenny. Tel: 056 7784761 & 056 7784763

Cavan/Monaghan HSE Nursing Homes Support Ofﬁ ce, Lisdarn, Cavan.

Tel: 049 4373155/112/191

Cork/Kerry HSE Nursing Homes Support Ofﬁ ce, Floor 1, Áras Sláinte,

Wilton Road, Cork. Tel: 021 4923536/37/38/39/40/41/42

Donegal HSE Nursing Homes Support Ofﬁ ce, Donegal PCCC HQ,

StJoseph’s Hospital, Stranorlar, Lifford, Co Donegal.

Tel: 074 9191734 / 074 9191740 / 074 9191733

Dublin South, Wicklow and Kildare HSE Nursing Homes Support Ofﬁ ce, Oak House, Millennium Park,

Naas, Co Kildare. Tel: 045 880400

Dublin North City and County HSE Nursing Homes Support Ofﬁ ce, Civic Ofﬁ ce, Main Street,

Ballymun, Dublin 9. Tel: 01 8467148

Galway HSE Nursing Homes Support Ofﬁ ce, Community Services,

Lá Nua, Ballybane Neighbourhood Village, Castlepark Road,

Ballybane, Galway. Tel: 091 748485

Laois/Offaly

HSE Nursing Homes Support Ofﬁce, Health Centre, Bury Quay,

Tullamore, Co.Offaly.

Tel: 057 93 27823 / 057 93 27826 / 057 93 27822

Limerick, Clare and North Tipperary HSE Nursing Homes Support Ofﬁ ce, St Joseph’s Hospital,

Mulgrave Street, Limerick. Tel: 061 461499

Longford/Westmeath HSE Nursing Homes Support Ofﬁ ce, Health Centre,

Longford Road, Mullingar, Co Westmeath. Tel: 044 9394995

Louth/Meath HSE Nursing Homes Support Ofﬁ ce, Unit 3 Ardee Business Park,

Hale Street, Ardee. Tel: 041 6871515/529/525

Mayo HSE Nursing Homes Support Ofﬁ ce, St Mary’s Headquarters,

Castlebar. Tel: 094 9049176

Roscommon HSE Nursing Homes Support Ofﬁ ce, Government Buildings,

Convent Road, Roscommon. Tel: 090 6637561/46

Sligo/Leitrim HSE Nursing Homes Support Ofﬁ ce, Markievicz House,

Barrack Street, Sligo. Tel: 071 9155193

Tipperary South HSE Nursing Homes Support Ofﬁ ce, Community Care Centre,

Western Road, Clonmel. Tel: 052 6177283

Waterford HSE Nursing Homes Support Ofﬁ ce, Waterford Community

Services, Cork Road, Waterford. Tel: 051 842963

Wexford

HSE Nursing Homes Support Ofﬁce, Wexford Community Services,

Georges Street, Wexford. Tel: 053 91 14315 / 053 91 14316

You can read more about this scheme on www.hse.ie. Information is also available from the HSE infoline

on 1850 24 1850, Monday to Saturday, 8am to 8pm

Nursing Homes Support Scheme Application Form

02911-HSE-NHSS-Proof#06-Final-Application.indd 12 06/03/2017 11:18

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