Evidence of Disability Form 2027 Sections 1-8
Please complete all sections below in TYPE or BLOCK capitals:
1. Applicant details
Title and Full Name of Applicant
Date of Birth
CAO Number
2. Medical Consultant/Specialist who made the diagnosis (GPs should not enter their own details here, see further instructions below)
Name and Title of Consultant/Specialist
Position/Professional Credentials
Date of Report
Date of onset of disability
Date of diagnosis by consultant
Date of Referral from GP to Consultant/Specialist
Note for GPs: If form is completed by a GP, GP must tick the following box
I have sufficient information on file from the appropriate consultant/specialist named above, diagnosing the applicant with one or more of the conditions indicated in Section 3.
I have provided the applicant with a copy of a document in which their diagnosis is confirmed by the appropriate consultant/specialist and is within the specified time limit (if one applies) for submission with this form.
If the information is on file, please complete sections 2-8 as appropriate.
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Official Stamp Required: This form must be stamped on page 6. If a stamp is not available, this form must be accompanied by a business card OR headed paper.