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
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
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: firstname.lastname@example.org
Please do not send your completed form to this address. Send it to the address on Page A of this form.
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
Any other income you or your partner get
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
Premiums for special needs because, for
example, you or your partner are disabled, or
get a component with your Employment and
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
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
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