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.