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.