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HC1
Do you find it difficult to pay for health costs?
You may be entitled to help through the NHS Low Income Scheme
Use this form if you need help with paying for:
• NHS prescriptions;
• NHS dental treatment;
• NHS wigs and fabric supports;
• sight tests, glasses and contact lenses; or
• travel to receive NHS treatment if referred by a doctor (GP or hospital doctor), optician or
dentist.
You might not have to pay or you could be entitled to some help towards the cost.
You can claim at any time.
Do not wait until you need treatment.
You can claim for:
• yourself;
• your partner; or
• your children.
If you need help or have any questions about filling in this form, you can phone our customer
enquiry line on
0300 330 1343.
If English is not your first language, phone this number and we will
provide an interpretation service over the phone.
Claim for help with health costs
You do not need to fill in this form if you or your partner are:
• getting Income Support;
• getting Pension Credit Guarantee Credit;
• getting Universal Credit and you had no earnings or net earnings of £435 or less during the
most recent assessment period (£935 if you had a child element or had limited capability for
work);
• getting income-based Jobseeker’s Allowance;
• getting income-related Employment and Support Allowance;
• named on, or entitled to, an NHS Tax Credit Exemption Certificate;
• or if you are under age 20 and someone is getting one of the benefits listed above which
includes you as a dependent.
You are already entitled to full help with health costs.
However, if you paid any health costs
before
you started getting any of these benefits or
before
you became entitled to your NHS
Tax Credit Exemption Certificate, read of this form to find out if you can claim your
money back.
You cannot get help with health costs if you or your partner (or both) have more than:
• £16,000 in savings, investments or property (not counting the place where you live); or
• £23,250 in savings, investments or property if you live permanently in a care home.
page C
Important note.
If you are living in a care home or are aged 16 or 17 and have just left
local-authority care, you may be able to use the shorter form, HC1(SC). Phone our customer
enquiry line on
0300 330 1343
and we will tell you what to do.
Some notes to help you
Page A
Please read the notes on this page and page B before filling in this form - they will help you to
claim correctly. Then pull off and keep them for information.
From the information you give us in this claim form, we will work out how much help you can get
through the NHS Low Income Scheme.
Work carefully through this form. In most of the form we ask you to tick a No or Yes box and give
any details needed. The notes in the form will tell you what to do next. If you need more space for
any of your answers, use of this form.
What we need to know about
. We need to know about you and, if you are a member of a couple
about your partner and any income and savings that you both have.
What we mean by partner.
We use the term ‘partner’ to mean a person you live with as part of a
couple of the same or opposite sex, whether or not you are married or have a civil partnership.
If we ask for evidence.
If you are working, in full-time education or a trainee, you will be asked to
provide evidence of your income. We accept photocopies as evidence. It will delay your claim if
you do not send us the evidence we ask for. If you are not sure what evidence to send (or don’t
have it), phone our customer enquiry line for advice on
0300 330 1343, Monday to Friday
between 8 am and 6 pm or Saturday between 9 am and 3 pm
.
If you are claiming money back.
of this form tells you how to claim money back. Use
of this form to tell us if your circumstances changed between the date you paid and the
date you signed this form.
If you have claimed before.
You still need to fill in this form with your current details as we need to
know your circumstances at the date of this claim. Even small changes to rent, mortgage or Council
Tax payments or the yearly increase in benefits or earnings can affect the amount of help you are
entitled to.
When you have fill
ed in this form.
Send it to: Low Income Scheme, NHS Business Services
Authority, Bridge House, 152 Pilgrim Street, Newcastle upon Tyne, NE1 6SN. A stamp is needed.
Postage costs may differ depending on the size of the envelope you use.
If you are filling in this form for someone else, they are responsible for making sure the
information is correct. They should tell you what to write for them and they should sign or make
their mark in
.
If you are filling in this form for someone with learning difficulties or a
condition that prevents them from managing their own affairs, you are responsible for making
sure the information is correct. You should sign the form yourself in . If you are not sure if
you can sign the form for someone else, phone our customer enquiry line for advice on
0300 330
1343, Monday to Friday between 8 am and 6 pm or Saturday between 9 am and 3 pm.
Your claim will be assessed by the
NHS Business Services Authority
at
Bridge House, 152 Pilgrim Street, Newcastle Upon Tyne, NE1 6SN.
We will normally deal with your claim within 18 working days from the date we get your form. If
we need more information, we will normally work out what help you can get within five working
days of receiving that information.
If you are entitled to help, we will send you a certificate telling you how much, if anything, you
have to pay towards your health costs. You should get your certificate within four weeks of the
date you make your claim.
If you need a new certificate, please fill in and send us a new HC1 form.
If you have any questions about your claim, or have not heard from us after four weeks, you can
phone our customer enquiry line on
0300 330 1343, Monday to Friday between 8 am and 6 pm or
Saturday between 9 am and 3 pm.
We respect customer confidentiality at all times. We will only give information about your claim
to another person with your permission. They will need to quote your certificate reference
number.
Page C
box 10a
part 9
part 9
box 10b
pages A, B and C
What you can expect from us
If you are filling in this form for someone else
How to make your claim
Make sure you read the notes on (inside front cover) as well.
From the information you give us in this claim form, we will compare your ‘income’ with your
‘requirements’ to work out how much help you can get through the NHS Low Income Scheme (see
below).
Our calculation is based on your circumstances on the date we receive your claim form, and any help
you are entitled to starts from this date. It is very important that you send the form to us as soon as
you can.
The NHS Business Services Authority is responsible for this service. We’ll use the information you give us to work out
your claim for help with health costs and help plan and make improvements to NHS services, and/or direct patient care.
By law, we must process this information to be able to provide this service. We may use your information to check
claims you make for help with NHS charges. If we can’t confirm that you’re entitled to help, you may be sent a Penalty
Charge Notice, and also have to repay the prescription charge.
Your information will not be transferred outside the European Economic Area.
To prevent, detect and investigate fraud and errors, we may share your information with NHS commissioners and
service providers, NHS England, the Department for Work and Pensions, HM Revenue and Customs, the NHS Counter
Fraud Authority and other relevant bodies and agencies.
Your personal data will be deleted from our systems and files no later than 24 months after the date of expiry on the
certificate or assessment. We keep your information to check that you have a valid exemption certificate when you
claim any help with NHS costs.
The information you have provided will be managed as required by Data Protection law. You have the right to receive
a copy of the information the NHSBSA hold about you, request that your information be changed if you believe it was
not correct at the time you provided it and request that your information be deleted if you believe we are keeping it
for longer than necessary.
Find out more about your rights and how we process information at www.nhsbsa.nhs.uk/yourinformation or contact:
Data Protection Officer, NHS Business Services Authority, Stella House, Goldcrest Way, Newburn Riverside, Newcastle
Upon Tyne, NE15 8NY.E-mail: nhsbsa.dataprotection@nhs.net
Please do not send your completed form to this address. Send it to the address on Page A of this form.
page A
‘Income’
includes the following.
•
Earnings after tax, National Insurance and half
of any pension contributions are taken off.
•
Social security benefits and pensions.
•
Work pensions or superannuation pensions.
•
Student grants, loans and any assessed parental
contributions (whether or not paid).
We will consider a student loan to be
income if you would be entitled to claim one,
whether or not you choose to take it
up. This includes any income related and
non-income related parts.
•
Money from trust funds.
•
War Disablement Pension or War Widow’s
Pension.
•
Any other income you or your partner get
regularly.
‘Requirements’
include the following.
•
Personal allowances for you and your partner.
These are at rates approved by Parliament for
daily living expenses, which include things like
water rates, fuel bills, phone bills, TV rental and
house insurance.
•
Premiums for special needs because, for
example, you or your partner are disabled, or
get a component with your Employment and
Support Allowance.
•
Housing costs that you and your partner are
responsible for. These include mortgage
repayments and rent not covered by Housing
Benefit or local housing allowance. Housing costs
do not include money you pay to another
member of your family.
•
Council Tax that you or your partner are
responsible for.
The rates of personal allowances and
premiums usually increase once a year, typically in
April, in line with Income Support arrangements.
If you want more information about this, visit our
website at
www.nhsbsa.nhs.uk/healthcosts
Note:
Note:
Page B
These notes are only guidelines. We will assess your claim individually.
Some notes to help you
How we assess your claim
How we collect and use information
Help, advice and claiming money back
© Crown Copyright 2018 Produced on behalf of the Department of Health and Social Care HC1 September 2018
Claim for help with health costs
• If you would like more information about help with health costs, you can download leaflet HC11 ‘Help with health costs’
from www.nhs.uk/healthcosts.
• If you want advice about this claim, or help filling in the form, phone our customer enquiry line on
0300 330 1343,
Monday to Friday between 8 am and 6 pm or Saturday between 9 am and 3 pm
, or write to us at NHS Business Services
Authority, Help with Health Costs, Bridge House, 152 Pilgrim Street, Newcastle Upon Tyne, NE1 6SN.
• If you would like information about free prescriptions and other NHS charges and costs, please phone our customer
enquiry line on
0300 330 1343
.
• If you would like a list of current NHS charges, you can get leaflet HC12 ‘A quick guide to help with health costs including
charges and optical voucher values’ from Jobcentre Plus offices, NHS hospitals, some NHS practitioners or by visiting
www.nhs.uk/healthcosts.
• If you have any other questions, please contact an advice service like Citizens Advice.
We must receive refund claims within three months of the date you paid, or in the case of a sight test within three months of
the date of the test. If you make a claim after three months, we have to decide if there is good reason for it being late
before we accept it. Please send an explanation with your claim if it is made after 3 months.
Our calculation is based on your circumstances at the time you paid. Tell us at if your circumstances were different
when you paid.
NHS prescription charges
You need to send us NHS receipt form FP57 - you get this from your pharmacist, doctor or hospital when you pay for your
prescription (you cannot get one later). It tells you what to do.
Other health costs
part 9
To claim a refund for:
• NHS dental treatment;
• NHS wigs or fabric supports;
you will need:
• sight tests;
• glasses or contact lenses; or
• NHS travel costs if referred by a
doctor (GP or hospital doctor)
dentist or optician;
• a receipt which shows what you
have paid for; and
• The appropriate refund claim form
HC5 for the charge you paid, (it tells
you what to do); and
• your optical prescription, if you are
claiming back money you have paid
for glasses or contact lenses.
If you need form HC5
You can usually get form HC5 from a Jobcentre Plus office and NHS hospitals. You can also ask for one at
www.nhsbsa.nhs.uk/healthcosts or you can phone
0300 123 0849.
If you are claiming more than one type of refund (for example, dental charges and glasses), you need to fill in a
separate HC5 form for each type of charge you have paid. Please ask for the version you need.
People getting Income Support, Pension Credit Guarantee Credit, Universal Credit with earnings within the allowed limits,
income-based Jobseeker’s Allowance, income-related Employment and Support Allowance or named on or entitled to an NHS
Tax Credit Exemption Certificate.
If you now get one of the above benefits or tax credits, but want to claim money back for
something you paid for before you were getting any of these benefits (because you were on a
low income) use this form to tell us about your circumstances on the date you paid. Mark the
front of the form ‘Refund only’ and tell us in which benefit or tax credit you get. Refund
claims must be received within three months of the date paid or the date of the eye test.
part 9
Note:
Help and advice
How to claim money back that you have already paid
Page C
1
Do you have a partner?
For an explanation of what we mean
by ‘partner’, see .
page A
1.2
Personal details - Please write in BLOCK CAPITALS.
Address and postcode
Phone number
(including dialling code)
You Your partner
Please read the notes on before filling in this form.
If you need help or have any questions about filling in this form, you can
phone our customer enquiry line on 0300 330 1343.
To check your entitlement, we may pass relevant information you have
given on this form to other public organisations, including to the Department for
Work and Pensions and local authorities.
Note:
pages A and B
Surname or
family name
We may need to contact you about your
claim. Please tell us your preferred method
of communication if we do.
Go to
.
part 2
1.3
Claim for help with health costs
HC1
Date
Time
Official Use Box Phone 1 Phone 2
Date
Time
About you and your partner
Part 1
No
Yes
(Mr,Mrs,Miss,Ms,other)
First name
Date of birth
National Insurance
number
/ / / /
Please answer all the questions that apply to
you.
Please answer all the questions that apply to
you and your partner.
If you are claiming a refund of health costs you have already paid, please
tick which ones. Please read the notes on to see what you need to
send to make your refund claim.
page C
1.1
NHS prescriptions
P
NHS dental treatment
P
A sight test
P
Glasses or contact lenses
P
NHS wigs or fabric supports
P
Travel to receive NHS treatment
P
E-mail address
Mobile number
Children and qualifying young people
Part 2
2
Children and qualifying young people are:
• children under 16 who normally live with you; and
• young people aged 16, 17, 18 or 19 who normally live with you providing they are:
- receiving full time education; or
- are on an approved training course which started before their 19th birthday
and they are not
- doing a course that is higher than A Level, Scottish Highers or equivalent, or
- in education received through their employer because of their work.
For a training course to be approved it should be one of the following:
• England - Entry to Employment or Programme Led Apprenticeships
• Scotland - Get Ready for Work, Skillseekers or Modern Apprenticeships
• Wales - Foundation Modern Apprenticeships, Skillbuild or Skillbuild+
Don’t count young people who have permanently finished an education or training course like
these. Tell us about them in . Don’t count children or young people who are boarding with
you, or foster children. Tell us about them in and use to tell us about any money you
get for looking after them.
Note:
part 5part 3
part 3
Do you have any children or qualifying young
people who live with you and who you support?
2.1
Go to
.
part 3
Give details below.
Go to
.
part 3
Yes
No
Relationship to youDate of birthFirst nameSurname or family name
/ /
/ /
/ /
/ /
/ /
/ /
/ /
Does anyone else live with you in your home?
Tell us about them below and tick whichever boxes apply.
Surname or family name
3.1
We need to know about any other people who live with you in your home.
We need this information
to make sure we work out your housing costs correctly.
Person 1 Person 2 Person 3 Person 4
If more than four people live with you, tell us about the others at
.
part 9
Other people living in your home
Part 3
Go to question
.
3.3
Give details below.
Yes
No
First name
Age
Relationship to you
3
On youth training
P
Full-time student
Gets Income Support
Gets Pension Credit
Gets income-based
Jobseeker’s Allowance
Gets the middle or higher
rate care component of DLA
Gets Attendance Allowance
Is severely sight impaired or is
registered blind
Gets money from work
Gets income-related Employment
and Support Allowance and has
not been placed in either the
work-related activity group or
the support group
P
Gets Universal Credit and does
not have any earned income
Gets the daily living
component of Personal
Independence Payment
Gets Armed forces
independence payment
No
Yes
No
Yes
No
Yes
No
Yes
£ £ £
On average, does the person named above work for 16 hours or more a week?
£
If the person named above works, please tell us how much money they have coming in each
week. You don’t have to tell us, but if they don’t have much money coming in, you might get
more help.
Include their earnings before tax and National Insurance are taken off - also include any other money they
have coming in. Don’t include their Attendance Allowance, Disability Living Allowance, Personal Independence Payment
or Armed forces independence payment if they get it.
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P P P P
P P P P
P P P P
P P P P
P P P P
P P P P
P P P P
Please tell us about:
• children and young people you have
not already told us about at ;
• relatives who live with you;
• friends who live with you; and
• boarders and lodgers - please tell us
about them in question .
part 2
Do not tell us about:
• people you have already told us about in
;
• co-owners;
• co-tenants, if you are a full-time student and
they live in the same accommodation as you;
• landlords;
• other residents, if you live in a care home; or
• relatives or friends you live with.
parts 1 and 2
3.3
Are any of the people you have told us about in
question living together as a couple of the
same or opposite sex, whether or not
they are married or have a civil partnership?
3.1
3.2
(name) is the partner of (name)
(name) is the partner of (name)
Do you or your partner have boarders, lodgers or
subtenants living with you?
Don’t count people who live as part of your family.
Tell us about them at question
.
3.1
3.3
Name
No
Yes
How much do they
pay?
Does it include
heating?
Does it include any
meals?
Person 1
£
every
No
Yes
Go to
.
part 4
Person 2
£
every
Person 3
£
every
Other people living in your home
Part 3
Give details below.
Yes
No
Give details below.
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
4
What is the address of this property or land?
What is the value of the property or land?
£
£
Do you or your partner have savings or any other
money in this country or abroad?
4.1
Savings means things like:
• money in bank, building society and post office accounts, including current accounts and savings
accounts;
• Premium, Income or Capital Bonds;
• shares;
• National Savings Certificates;
• unit trusts, Personal Equity Plans (PEPs), Individual Savings Accounts (ISAs) and other investments; and
• any other money.
If you have a partner (for an explanation of what we mean by ‘partner’ see ) and you both have
savings, we need you to tell us the combined amounts. If you do not know the value of any of your savings and
investments, please check your most recent statements.
page A
Note:
Money in accounts - tell us the total amount held in accounts
Premium Bonds - tell us the face value
Income or Capital Bonds - tell us the face value
£
£
£
Shares - tell us about them below
Name of the company the shares are held in and the type of shares held Number of shares held
Unit trusts, PEPs, ISAs and other investments
- tell us the current value, after any selling costs
Do you or your partner own any property or land
in this country or abroad?
Don’t include the place where you live.
4.2
How much, if anything, is still owed on the property or land?
£
We may need to contact you if we need more information about this.
Go to
.
part 5
About property, savings and other money
Other people living in your home
Part 4
Give details below.
Yes
No
Give details below.
Yes
No
National Savings Certificates - tell us about them below
Please tell us exactly how much they are worth now
Any other money - for example, any cash you have
£
5
P
P
P
P
P
P
P
Note: Tell us about any Attendance Allowance, Disability Living Allowance, Personal Independence Payment and
Armed forces independent payment at questions
, and .
Do not tell us about, Local Housing Allowance or Council Tax Reduction.
5.55.45.3
We need to know about all income that you get. Tell us about your work in . Tell us about
your student income in . Use this part to tell us about everything else.
• If you are getting
Pension Credit Guarantee Credit
you do not need to use this form – see
the note on the front cover. If you are not sure what type of Pension Credit you receive, the
page ‘How your Pension Credit was worked out’, sent with the letter that told you that you
were entitled to Pension Credit, shows if you get Guarantee Credit.
• Include anything that is paid to someone else on your behalf or that you get for someone
else.
• If you get pensions or benefits paid together, list them separately. Your order book or the
letter about the benefits or pensions will tell you what you are getting.
part 8
part 6
Do you or your partner get any social security
benefits or pensions?
5.1
Name of benefit
Tell us about:
• private pensions;
• pensions from previous employers;
• money from a trust fund;
• maintenance payments;
• vouchers;
• other payments not from
social security, for example, Child Tax Credits
or Working Tax Credits;
• money from a charity or voluntary
organisation; and
• any other income that you have not already
told us about.
Do you or your partner get any other income?
Don’t include work or student income here.
5.2
About your income
Part 5
Give details below.
Yes
No
Who is it for? How much do you get?
£ every
£ every
£ every
£ every
£ every
£ every
Type of income Who is it for? How much do you get?
6
If you receive Pension Credit, do not include it with any State Retirement Pension.
List Pension Credit Savings Credit payments separately at question
.
5.1
Give details below.
Yes
No
Tell us about the following.
• State Retirement Pension
• Incapacity Benefit
• Severe Disablement Allowance
• Industrial Injuries Disablement Benefit
• Statutory Sick Pay
• Contribution-based Jobseeker’s Allowance
• Contribution-based Employment and Support
Allowance
• Universal Credit
• Maternity Allowance
• Pension Credit (Savings Credit)
• War Disablement Pension
• War Widow’s Pension
• Widow’s Benefits
• Bereavement Allowance
• Widowed Parent’s Allowance
• Carer’s Allowance
•Any other social security benefit (see note
below)
£ every
£ every
£ every
£ every
£ every
You Your partner
Give details below.Give details below.
Give details below.Give details below.
No
Yes
High rate?
Low rate?
Tick which rate below.
No
Yes
High rate?
Low rate?
Tick which rate or rates below.
No
Yes
Mobility component
High rate?
Middle rate?
Low rate?
Care component
No
Yes
No
Yes
When did they tell you?
/ /
/ /
Over a year ago?
No
Yes
When did you start sending them in?
Less than a year ago?
Tell us the exact date.
/ /
High rate?
Low rate?
High rate?
Low rate?
Tick which rate below.
No
Yes
Do you or your partner
get Attendance Allowance?
5.3
Over a year ago?
Are you or your partner sending sick notes to your local social security office or
employer at the moment?
5.6
No
Yes
When did you start sending them in?
Less than a year ago?
Tell us the exact date.
Are you or your partner looking after someone but cannot get Carer’s
Allowance because you get another benefit instead?
Carer’s Allowance is paid to someone caring for a severely disabled person. It used to be called Invalid Care
Allowance. It is not Attendance Allowance or Disability Living Allowance.
5.8
No
Yes
Does someone other than you or your partner get Carer’s Allowance or an award of
universal credit which includes the carer element for looking after either of you?
5.9
No
Yes
Do you or your partner get
Disability Living Allowance?
5.4
Tick which rate or rates below.
No
Yes
Has your local social security office said that you are not capable of work and
that you don’t have to send in sick notes?
5.7
No
Yes
Go to
.
part 6
About your income
Part 5
When did they tell you?
/ /
Mobility component
High rate?
Middle rate?
Low rate?
Care component
7
Enhanced rate?
Standard rate?
Tick which rate or rates below.
No
Yes
Mobility component
Enhanced rate?
Standard rate?
Daily living component
Enhanced rate?
Standard rate?
Do you or your partner get Personal Independence Payment or Armed forces
independence payment?
5.5
Tick which rate or rates below.
No
Yes
Mobility component
Enhanced rate?
Standard rate?
Daily living component
Armed forces independence payment?Armed forces independence payment?
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
You Your partner
Give details below.Give details below.
Go to
.
part 7
Go to
.
part 7
Self-employed
How much do you pay?
No
Yes
£ every
No
Yes
Give details below.
How much do you pay?
Employed
In this part of the form we need to know about any money that you or your partner receive for any
work you are doing now.
This includes:
Do you or your partner have a job?
6.1
• work for an employer;
• self-employed work;
• full-time or part-time work;
• permanent or casual work;
• paid voluntary or charity work;
• training schemes; and
• overtime and tips.
6.2a
Please tell us how often you are paid and provide photocopies of the payslips we ask
for below as evidence of your earnings. If you cannot provide these, please phone our
customer enquiry line on 0300 330 1343 and we will tell you what to do. If you are
employed on a zero hours contract, you do not work every week or your earnings vary
from week to week tick the first option.
Every week
Every two weeks
Every four weeks
Every month
No
Yes
No
Yes
Give details below.
How many hours do you normally work each week?
What is your job?
What type of work is it?
Tick all the boxes that apply in the rest of this part and give the information we ask for.
6.2
Do you or your partner pay anything towards a personal pension?
Do not include anything you pay into a works pension as this will be shown on your payslips.
6.3
Self-employed
6.2b
About work
Part 6
£ every
Please send us a copy of your accounts for the financial year ending within
the last 12 months. If you cannot provide these, please phone our customer
enquiry line on 0300 330 1343 and we will tell you what to do.
Note: We cannot accept HM Revenue & Customs self-assessment forms as evidence of self-employed income.
Send last four payslips.
Send last four payslips.
Send last two payslips.
Send last two payslips.
6.2b
Employed
6.2a
8
P
P
P
P
Every week
Every two weeks
Every four weeks
Every month
Send last four payslips.
Send last four payslips.
Send last two payslips.
Send last two payslips.
P P
P
P
P
P
P P
Zero hours contract
do not work every
week or earnings
vary
Send last five payslips.
P
Zero hours contract
do not work every
week or earnings
vary
Send last five payslips.
P
Please provide a letter from your training provider showing your allowance.
You Your partner
Give details below.Give details below.
Give details below.Give details below.
Please send us a photocopy of your most recent payslip and say what period it covers (for
example, every week or month). If you cannot provide this, please phone our customer
enquiry line on 0300 330 1343 and we will tell you what to do.
No
Yes
/ / / /
Are you or your partner sending sick notes to your employer at the moment?
If you are sending sick notes to your local social security office, please give details at question
.
5.6
6.4
Are you or your partner on a training scheme?
6.5
No
Yes
Trainee
GIve details below.
Employee
Are you paid as a trainee or as an employee?
Name of scheme
Period payslip covers
When did you start sending them in?
No
Yes
Period payslip covers
Go to
.
part 7
Name of scheme
Go to question
and send the payslips
we ask for.
6.2a
About work
About work
Part 6
When did you start sending them in?
No
Yes
Trainee
Give details below.
Employee
Go to question
and send the payslips
we ask for.
6.2a
9
6.5a
P
P
P
P
Go to .
part 8
Go to question
.
7.3
Go to question
.
7.5
Do you have just one room?
Don’t count rooms you share with people who are not part of your family.
£
every
Are you or your partner a joint owner or tenant
of the place where you live?
7.3
Do you or your partner live with parents, relatives
or friends in their home?
Tick if you are in hospital but normally live with parents,
relatives or friends.
Yes
7.2
Do you or your partner pay rent for the place
where you live?
If you pay money to parents, relatives or friends, tick and go to . We do
not need to know about any money that you pay to them.
If you are a
student
and pay rent for the place where you live, tick . We ask you
to tell us about the rent you pay at
.
part 8
No
part 8No
7.4
How much do you pay? Take off housing benefit and local housing allowance if
you get it. Do not take off the housing element of universal credit if you get it.
Don’t include water rates, Council Tax or arrears.
If you are waiting to hear about a claim for local housing allowance or housing benefit, tell us what
you currently pay.
Take off amounts for heating, lighting, cooking or hot water if they are included in your rent and
you know the amounts.
If heating, lighting, cooking and hot water are included in your rent and you do not know
the amounts, please tick the relevant boxes below.
Does your rent include any of these things?
Tick the relevant boxes.
If it does not, or if you have already taken amounts for these things off
your rent, leave the boxes blank.
Heating
Lighting
Cooking
Hot water
No
Yes
No
Yes
Are you or your partner in hospital?
No
Yes
7.1
Give details below.
• to a private landlord or landlady;
• to a local council;
• to a housing association;
• for a room in a bed and breakfast, hostel or hotel;
• for ground rent;
• for a mortgage;
• for Council Tax; and
• for service charges.
Give details below.
About where you live
Part 7Part 7
Yes
No
Give details below.
Yes
No
Give details below.
Yes
No
/ /
Name of the person who is in hospital
Date they went into hospital
In this part we need to know about your share and your partner’s share of anything you pay for
the place where you live.
Please tell us about money you pay:
Who with?
What is their relationship to you or your partner?
Does your rent include any meals?
How many breakfasts each week for each person?
How many midday meals each week for each person?
How many evening meals each week for each person?
10
P
P
P
P
Every
£
How much do you have to pay for the loan?
Don't include arrears or any amount that you voluntarily overpay.
£
Every
£
Every
Do you or your partner have to pay Council Tax?
Don’t include Council Tax for property you have told us about in
.
part
4
7.5
Do you or your partner own your own home?
If you have a mortgage or secured loan, still tick .
Also tick if you partly rent and partly own your home.
Yes
Yes
No
Yes
7.6
Go to question
.
7.8
Go to question .
7.7
Do you or your partner have a mortgage or loan
secured on your home?
No
Yes
7.7
Give details below.
How much do you have to pay for the mortgage or loan?
Include any endowment premiums linked to the mortgage.
Don’t include premiums for any other type of insurance.
Don't include arrears or any amount that you voluntarily overpay.
Do you or your partner pay ground rent?
In Scotland, this is called feu duty.
No
Yes
7.8
Give details below.
How much ground rent do you pay?
Don’t include arrears.
£
Do you or your partner have to pay any service
charges for the place where you live?
Service charges are charges you have to pay to live in your home for things like
cleaning and maintaining shared areas, such as hallways and stairs.
No
Yes
7.9
Give details below.
Every
How much do you pay?
Don’t include charges for ordinary gas, electricity, meals or cleaning your own rooms.
Don’t include arrears, or any other bills that you pay separately from your service charges.
Take off Housing Allowance if you get it.
What is it paid for?
Do you or your partner have a loan to adapt your
home for the special needs of a disabled person?
Tick if the disabled person is an adult and has savings or property
of more than £16,000.
No
No
Yes
7.10
Give details below.
Name of the disabled person
Go to
.
part 8
About where you live
Part 8Part 7
Give details below.
Yes
No
£
How much do you have to pay for this year?
Tell us the amount you actually have to pay.
Don’t include arrears, and in Scotland don’t include water or sewerage rates.
Has the local authority assessed your resources,
and as a result, you get help with the cost of your
care home accommodation?
No
Yes
7.12
11
Go to .
part 8
Are you or your partner living permanently in a
care home?
If you live in sheltered accommodation, tick and answer question
.
7.4No
7.11
Yes
No
You Your partner
Go to
.
part 9
Go to
.
part 9
No
Yes
What is your normal country of
residence when you are not a
student?
/ /
Date when your next year starts
No
Yes
/ /
Date when your next year starts
No
SAAS
Who pays?
No
Yes
Tick who pays. SFE
NHS
SAAS
Are you or your partner in education?
Only tick if you have actually started your course.
Yes
8.1
Who pays?
• We need to know about amounts of money you either receive or pay out. If you give a
yearly amount, please say whether you mean 52 weeks a year or academic year.
starts / / ends / /
Give details below.
No
Yes
Term 1
Are you or your partner an overseas student?
8.2
Are your or your partner’s tuition fees paid by Student Finance England (SFE), Student
Finance Wales (SFW), the Student Awards Agency for Scotland (SAAS) or the National
Health Service (NHS)?
No
Yes
8.3
Tick who pays. SFE
NHS
starts / / ends / /Term 2
starts / / ends / /Term 3
starts / / ends / /Term 1
starts / / ends / /Term 2
starts / / ends / /Term 3
People in education
Part 8
Give details below.
No
Yes
Qualification, full-time or part-time details and whether post-graduate or undergraduate
Name of school, college or university
Exact dates of terms of the current academic year
Please contact your college or university if you do not know them.
We cannot accept semester dates. Terms are normally separated by Christmas and Easter holidays.
It may delay your claim if you do not provide your exact term dates.
If you are making this claim in the summer holiday, please give exact term dates for last academic
year and next academic year. Use if you need more space.
part 9
Are you in the final year or only year of your course?
12
Yes
No
Yes
What is your normal country of
residence when you are not a
student?
P
P
P
P
P
P
SFW
P
SFW
P
Give details below.Give details below.
Every
Who pays this money to you?
No
Yes
EveryEvery
Tuition fee support
Loan support
Grant support
Tuition fee support
Support from Student Finance England (SFE), Student
Finance Wales (SFW) or the Student Awards Agency
for Scotland (SAAS)
This may be in the form of a loan and / or maintenance grant.
Send us the Student Finance Breakdown from the awarding body for you or
your partner.
It must be the Student Finance Breakdown.
We cannot accept the schedule of payments.
If you are making this claim in the summer holiday, please send a copy of last
year’s award notice and next year’s award notice (if you have received it).
Have you or your partner applied to SFE, SFW, the SAAS or the NHS for financial
support?
No
Yes
8.4
Tick each type of support you have applied for. Tick even if it was not paid.
Loan support
Grant support
What is the source of money you and your partner live on while you are in
education?
Tick the relevant boxes below. More than one box may apply.
8.5
You Your partner
Bursary from your higher education institution (HEI)
Send us the award notice showing how much you or your partner get.
For example, this may be a bursary from your HEI because you are charged
the maximum amount of tuition fees and your household has a low income.
Other scholarship, sponsorship, award or bursary
Send us the award notice showing how much you or your partner get.
Grant or loan from overseas
Send us the award notice showing how much you or your partner get.
If the award notice is not written in English, please translate it.
You Your partner
Money from parents
Include money received for rent
and living expenses but do not
include money received to pay
tuition fees. Please be exact.
Any other money
Do not include money for tuition fees.
Relationship to you
£
People in education
Part 8
£
£
Please send us the evidence we ask for. We cannot deal with your claim without it. If you are
making this claim in the summer holiday, please send a copy of last year’s student finance
breakdown/award notice and next year’s award notice (if you have received it). If you are not
sure what to send us, please phone our customer enquiry line on
0300 3301343
or visit our
website at www.nhsbsa.nhs.uk/healthcosts
13
Every
£
NHS Bursary
Send us the award notice showing how much you or your partner get.
If you have money coming in from part-time or full-time work, please fill in .
It tells you what you need to send.
part 6
P
P
P
P
P
P
P P
P P
P P
P P
P P
P
P
P
P
E.g. If you paid £50 per
week 40 times during this
period, enter £2,000. If
you paid £200 per month
and paid it 10 times, enter
£2,000. If you paid £600
per term, enter £1,800.
Holidays
Term
Holidays
Do you or your partner pay rent for the place
where you live, for example, money you pay for
halls of residence or to a private landlord?
If you pay money to parents, relatives or friends, tick and go to .
No part 9
.
Give details below.
Go to
.
part 9
£
How much do you pay in total for the period you have entered
above?
Take off amounts for heating, lighting, cooking and hot water if they are included in
your rent and you know the amounts.
If heating, lighting, cooking or hot water are included in your rent and you do not
know the amounts, please tick the relevant boxes below.
Heating
Lighting
Cooking
Hot water
Does your rent include any of these things?
Tick the relevant boxes that apply during term time and during your
Christmas and Easter holidays.
If it does not, or you have already taken amounts for these things off
your rent, leave the boxes blank.
Do you have just one room?
Don’t count rooms you share with other people who are not part of your family.
Does your rent include any meals?
Enter the number of meals included in the relevant boxes that apply during
term time and during your Christmas and Easter holidays.
How many breakfasts each week for each person?
.
.
Do you or your partner live with parents during
term-time?
No
Yes
8.6
Go to
.
part 9
No
Yes
8.7
No
.
Yes
No
Yes
Go to
.
part 9
People in education
Part 8
How many midday meals each week for each person?
How many evening meals each week for each person?
14
What date did you return (or will you return)
to your student accommodation after the
summer holiday?
8.8
/ /
Please tell us the start and end dates of the period for
which you are liable to pay these housing costs.
These dates may be for longer than your academic year.
Start
/ /
End
/ /
Term
Give details below.
P
P
P
P
P
P
P
P
Use this space to tell us anything else that you think we might need to know about you
and your partner (if you have one).
For example, tell us:
• what you are living on if you have not told us about any income;
• if you have a car on the Motability scheme;
• if you pay a charity or voluntary organisation for someone to live with you and look
after either of you;
• if you have money added to a student grant
or loan because you are deaf;
• if you are severely sight impaired or are registered blind; or
• if you know the amount of your benefit or pension is going to increase. Tell us what
you get now at and the new amount and the date of the increase below.
And also use this space to tell us anything else you think we might need to know about.
part 5
Other information
Part 9
15
Now complete your claim by signing the declaration at on
the next page.
part 10
You may get information about this claim from my partner as named on this form. I
confirm that the information I have given on this form is correct and complete, and I
understand that if it is not, appropriate action may be taken. For the purpose of
checking this, I agree to you giving relevant information to the Department for Work
and Pensions and other relevant bodies and agencies (see How we collect and use
information).
/ /
I have signed the declaration above.
I have attached my student award notices requested at (if this applies).
part 8
I have attached photocopies of the payslips as requested at (if this applies).
part 6
I have answered all the questions that apply to me.
Remember, we can deal with your claim more quickly if we get all the information we ask
for. Use the tick boxes to check that you have filled in the form as fully as possible.
Signature
Box 10a
Please read the declaration and sign and date below.
box 10a
When you have filled in this form.
Date
Declaration
Your claim is not valid unless it is signed and dated.
/ /
DateSignature
Box 10b
You may only make a claim on behalf of someone else for the reason given below.
You are responsible for making sure the information is correct.
You should read the declaration and sign and date below.
If you are not sure whether you are able to sign, please phone our customer enquiry
line on
0300 330 1343
.
box 10b
If you are claiming on behalf of someone else
Your name
Your address and
postcode
Your relationship to the person in
part 1
16
False information may lead to civil or criminal action. We expect the person signing this
form to take reasonable care to make sure the information given is correct. Anyone found
to have wrongly claimed help with NHS health costs may be issued a penalty charge or may
face prosecution.
Warning
Part10
I am responsible for this person’s financial affairs because they have learning
difficulties or a condition that prevents them from managing their own affairs.
If you are filling in the form for somebody, and this reason does not apply, they should tell you what to write for
them and they should sign or make their mark in .
box 10a
I confirm that the information I have given on this form is correct and complete, and I
understand that if it is not, appropriate action may be taken. For the purpose of checking
this, I agree to you giving relevant information to the Department for Work and Pensions
and other relevant bodies and agencies (see How we collect and use information). This is
my claim for help with health costs on behalf of the person named in .
part 1
© Crown Copyright 2018 Produced on behalf of the Department of Health and Social Care HC1 September 2018
I have given dates of terms as requested at (if this applies).
part 8
P
P
P
P
P
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