Rebuilt HTML — PaddleOCR-VL (Baidu)

Contents

Introduction Page 3 Part 1 – Patient’s details Page 5 Part 2 – Details of NHS wig or fabric support charges paid Page 6 Part 3 – Other information we need Page 7 Part 4 – Reason for your claim Page 8 Declaration and signature Page 11

Introduction

You can claim back the cost of NHS wigs or fabric supports.

You will need to complete an HC5(W) form to apply for a refund.

This guide will help you fill in your HC5(W) form.

The form is available online at www.nhsbsa.nhs.uk/hc5

You need to complete parts 1, 2, 3 and 4 of the form and the declaration and signature section. Do not complete part 5.

You can complete the form for yourself, or you can ask someone to do it for you.

If you need any further support to complete this form, please call us on 0300 330 1343.

How to complete the form for someone else

If you're filling in the form on behalf of someone else, you need to provide their details.

If you are filling in this form for someone who is physically incapable of doing so, ask them to tell you what to fill in for them.

If you are filling in the 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.

Time limit to apply

You must complete your claim within three months of the date you paid the charge.

If you apply after three months, you need to tell us why you're making the claim late. Send a written explanation with your HC5(W) form.

Part 1 – Patient's details

Fill in your personal details.

Surname: write your last name.

Other names: write your first name and any middle names.

Date of birth: write the date you were born (day, month, year).

Address: write your home address (street, town, postcode).

Email address: write your email if you have one.

Daytime phone number: write your phone number if you have one.

National Insurance No: write your National Insurance number.

Your number will be on tax-related documents like your payslip or P60. Or you can find it online at www.gov.uk/find-national-insurance-number

Part 2 – Details of NHS wig or fabric support charges paid

You need to send all original receipts which show the amount and date you paid for the NHS wig or fabric support, along with your HC5(W) form.

I wish to claim a refund of: write the total amount of money you have paid for the NHS wig or fabric support.

Paid on: write the date you paid the NHS charge.

Any refund due will be paid directly into your bank account.

Write the bank or building society account details you want to receive any refund you are entitled to.

Name(s) of account holder(s): write the name as shown on the bank account.

Full name of bank, building society or other account provider: find the name of the bank or building society on a bank statement or debit card.

Sort code: a six-digit number.

Account number: an eight-digit number.

Part 3 – Other information we need

Name, address and telephone number of the organisation who arranged for you to have a wig or fabric support: write the place name, address and telephone number. These details will be written on your referral letter or you can contract the organisation who referred you.

Part 4 – Reason for your claim

There are four groups listed in this section. You need to tick which one applied to you at the time you paid for your NHS wig or fabric support costs. If you're unsure about which benefit you receive look at your benefits award notice or contact your benefits office.

Tick Group 1 if:

• you receive a War Pension payment or an Armed Forces Compensation Scheme payment and you were being treated for your accepted disablement.

Send your HC5(W) form to: Service Personnel and Veterans Agency, Norcross, Blackpool, FY5 3WP.

Tick Group 2 if:

• you are named on an HC2 or HC3 certificate, or

If your name was on an HC2 or HC3 certificate, tick this box and write the number of the certificate and the name and date of birth of the certificate holder.

Send your HC5(W) form to: NHS Business Services Authority, Bridge House, 152 Pilgrim Street, Newcastle upon Tyne, NE1 6SN.

Tick Group 3 if:

• you were getting one of the listed benefits, or
• you are the partner, a dependant child or young person under 20 years old of someone who was getting one of the listed benefits

If you were getting one of the listed benefits, tick this box and the box next to the benefit you received.

If you are the partner, a dependant child or young person under 20 years old of someone who was getting one of the listed benefits, tick this box and write the name and date of birth of the person receiving the benefit. Also tick the box next to the benefit they received.

If you tick the box for Universal Credit, Income Support, Income-based Jobseeker's Allowance or Income-related Employment and Support Allowance send your HC5(W) form to your local Jobcentre Plus office.

You can find your local office online at https://find-your-nearest-jobcentre.dwp.gov.uk/

If you tick the box for Pension Credit Guarantee Credit, send your HC5(W) form to the Pension Centre who dealt with your claim.

Tick Group 4 if:

• Groups 1 to 3 do not apply to you, but you have a low income.

Tick the box relevant to you.

You need to fill in an HC1 form to apply to the NHS Low Income Scheme.

The form is available online at www.nhsbsa.nhs.uk/hc1 If you live in England, you can also order the form by calling 0300 1230849. Or you might be able to get an HC1 from NHS hospitals, GP practices or Jobcentres.

Send your HC5(W) and HC1 form to: NHS Business Services Authority, Bridge House, 152 Pilgrim Street, Newcastle upon Tyne NE1 6SN.

Declaration and signature

Read the declaration statement.

If the claim is for your NHS wig or fabric support costs, sign your name in Part 4A. Write the date when you signed the form.

If you are filling in this form for someone who is physically incapable of doing so, they should sign or make their mark in Part 4A.

If you are filling in the form for someone with learning difficulties or a condition that prevents them from managing their own affairs, you should sign your name in Part 4B. Write your name, address and telephone number.