Med 1/07 Application for medical advice ill health retirement
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1 Med 1/07 Application for medical advice ill health retirement This form has tw o parts. Part 1 is an application for medical advice from Capita Health Solutions w hich the employer completes. Part 2 is for the scheme member, asking their consent to release personal medical information Part 1 Application for advice (Pages 1 to 4 to be completed by the employer) If you need help to get the referral right you should refer to: The Medical Guidance Notes (w hich can be found on the CSP w ebsite at If you need more help you can us at pcsps.chs@capita.co.uk or ring the Capita Health Solutions helpdesk on Please provide information about you (the employer) so that w e can contact you when necessary and send an invoice for our services of department /agency/ndpb of referrer/contact Location code* (mandatory) * This is the location code that Capita Health Solutions have allocated to your office for charging purposes. If you do not have a location code, please telephone the helpdesk. Purchase order number (optional) Application to Capita Health Solutions for PCSPS IHR advice - page 1 of 7
2 2. Please provide information about the member (your employee) Surname Forenames Date of birth / / Payroll number Home address Daytime telephone number Mobile telephone number Male / Female (delete as appropriate) Weekly contracted hours Industrial / Non industrial (delete as appropriate) Nor mal retirement age Date from w hich Pension Scheme Service reckons Special needs Please provide details of any aids or adjustments (eg mobility, visual or hearing issues) that we need to make in our dealings w ith the scheme member Application to Capita Health Solutions for PCSPS IHR advice - page 2 of 7
3 3. Please tick the relevant box to show w hich pension scheme the member belongs to. It is important that you tell us w hich scheme the member is in, to prevent us giving you incorrect or incomplete advice. Scheme Classic Classic Plus Pre mium Partnership 4. When you are making an application for ill health retirement advice you must submit a file containing the documents in the list below. Each document must be flagged as show n below. You must not send any personal or other files to Capita Health Solutions. We w ill not consider any information that is not flagged. If, in exceptional circumstances, you cannot provide any of the documents you must explain why. We cannot provide the advice you need unless the forms are fully completed and all the documents (show n in the checklists in the supplementary forms) are supplied. If w e have to return the papers because items are missing or forms are incomplete, w e will identify the deficiencies and return the papers to you so that you can correct the matter and resubmit the papers. We w ill make a charge each time w e have to return an incomplete referral. Flag Documents required Enclosed 1. Details of consideration given to job modifications and redeploy ment (if redeployment has not been considered you should do this before submitting an application for ill health retirement). 2. Full occupational health records. This includes reports to management from your occupational health provider, the clinical notes (including notes of any consultations) upon w hich such reports are based, and any reports from your employee s doctors that your OH provider has obtained. The last tw o should be contained in a medical in confidence envelope. 3. Copies of any Capita Health Solutions (as scheme medical advisor) correspondence relating to the case. 4. If the member joined the Pension Scheme on or after 1 April 1998, include the PCSPS medical entry certificate (Capita Health Solutions Medical Opinion For m). If the member joined prior to 1 April 1998, include the original health declaration form. 5. Job description 6. Sickness absence record for last 5 years. 7. Performance report and administrative action taken in relation to sickness absence. Application to Capita Health Solutions for PCSPS IHR advice - page 3 of 7
4 5. Please confirm the follow ing by ticking the relevant box: That you have fully considered any adjustments including redeployment that w ould allow the member to continue their employ ment. (details attached - flag 1) There are no other outstanding employ ment matters relevant to this application (e.g. disciplinary proceedings or an Employment Tribunal. If there are, please give details below). 6. Please let us know whether this is w ill be a voluntary or compulsory medical retirement. This is an either/or question. You must not tick both boxes. This is an application for voluntary medical retirement This is an application for compulsory medical retirement 7. If this is an application for compulsory medical retirement please confirm the follow ing: The member is aw are of the application The member s service is to be terminated I understand that the Scheme Medical Adviser is only advising on qualification for PCSPS benefits. I understand that the Scheme Medical Adviser may need to examine this officer and/or obtain medical reports and they w ill charge for this. I have completed all the sections in this form and enclose the information required. Please send this application to: Capita Health Solutions Greyfriars 10 Queen Victoria Road Coventry CV1 3PJ Signed.. On behalf of Dept/Agency/NDPD Date. Application to Capita Health Solutions for PCSPS IHR advice - page 4 of 7
5 Part 2 Medical Consent Form (Pages 6 and 7 to be completed by the scheme member) Consent to release personal medical information in connection with an application for medical advice from Capita Health Solutions, the medical advisers to the Civil Service Pension and Compensation Arrangements Please read this section w hich gives information about your rights in relation to your medical records Under the terms of the Access to Medical Records Act 1988 You have the right to withhold your consent for Capita Health Solutions to apply to your family doctor or hospital specialist for medical information. If you give your consent, you have the right to see information about your medical condition before it is supplied to Capita Health Solutions. You will have 21 days from the date of Capita Health Solutions letter notifying you that a medical report has been requested to ask your family doctor or hospital specialist to let you see the report. If you regard any information in the medical report as incorrect or misleading, you can ask in writing for it to be amended (please note: if your family doctor or hospital specialist does not accept that the information is incorrect or misleading they are not required to make the amendment; but in these cases your family doctor or hospital specialist will invite you to prepare a written statement on the disputed information when it is sent to Capita Health Solutions). Subject to the provisions of the Act you have a right to see information about your medical condition for up to six months after it has been sent to Capita Health Solutions. If your family doctor or hospital specialist gives you a copy of the medical report at your request they may charge you a fee to cover the cost of its supply. Application to Capita Health Solutions for PCSPS IHR advice - page 5 of 7
6 Medical Consent Form 1. Your employer is asking for pension scheme medical advice. Please complete the form and read the declaration before signing below Surname Forenames Date of birth Home address 2. Do you w ish to exercise your rights to see the information supplied to Capita Health Solutions? Under the terms of the Access to Medical Records Act 1988 (see page 5 of this form) do you intend to ask your family doctor or hospital specialist /private consultant to let you see the information supplied to Capita Health Solutions? Yes No 3. To provide medical advice, w e may need to contact your family doctor and if appropriate your hospital specialist/private consultant. Therefore w e need to know their full name and address. Please complete the boxes overleaf if you have more than one specialist treating you. Family Doctor Hospital specialist/private consultant (1) Application to Capita Health Solutions for PCSPS IHR advice - page 6 of 7
7 Hospital specialist/private consultant (2) Hospital specialist/private consultant (3) 5. Declaration 1. By signing below, I agree to my family doctor or hospital specialist/private consultant giving information about my medical condition to Capita Health Solutions. 2. I understand the reason w hy my employer is making this referral to Capita Health Solutions (the medical advisers to the Civil Service Pension and Compensation Arrangements) 3. I understand that this information is medical in confidence and that any advice given to my employer about my health relating to my w ork w ill be in general ter ms only and handled in the strictest confidence. 4. I also understand that should I w ish to receive a copy of any information supplied to Capita Health Solutions by my family doctor or hospital specialist/private consultant, I may have to pay a fee for any report that is supplied to me. 5. I have seen and read the note in page 5 paragraph 1 above w hich provides information about my rights in relation to my medical records. 6. I understand that Capita Health Solutions may need to examine me in order to provide advice. If I turn dow n or fail to attend an appointment on tw o occasions, Capita Health Solutions w ill provide advice on the basis of the information available to them. Signature Date Application to Capita Health Solutions for PCSPS IHR advice - page 7 of 7
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Date of receipt: Transfer In Notes: Please read the accompanying notes before completing this form. You must ensure each section is fully completed by the appropriate party and only then should you submit
Tip Top Income Protection Claim Form
Tip Top Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields