Access to Medical Reports for Care Fees Annuities

Please complete all relevant sections of the form in BLOCK CAPITALS, sign, date and return to us at: Care Fees Annuities, Axxis House, 178a High Road, Byfleet, Surrey, KT14 7ED.

This form should only be completed by the legal representatives of the person needing care if they have the legal capacity to effect a Care Fees Payment Plan on receipt of the offer terms.

Please note that if the person needing care has become or is becoming mentally incapable of managing their own affairs, an Enduring/Lasting Power of Attorney (property and affairs) must be registered with the Court of Protection.

Details of the person needing care:

Full Name:

Address:

Date of Birth:

Please indicate which insurance companies you require Care Fees Payment Plan offer terms from:

Lifetime Care (Axa)

Partnership Assurance

Important Notes

Before the insurance provider can provide you (the applicant) with terms for its Care Fees Payment Plan it may need to obtain a medical report from any doctor who has attended the person needing care.

Please read this section carefully as it sets out the rights of the person needing care under The Access to Medical Reports Act 1988, or the Access to Personal Files and Medical Reports (NI) Order 1991 or the Isle of Man: Access to Medical Records and Reports Act 1993.

To apply for a medical report both the insurance provider and Medicals Direct Screenings Limited (hereinafter referred to as Medicals Direct), a firm working for each insurance provider, will need the consent of the person needing care, or of their legal representative. Consent is given by signing Section 1 below.

Medicals Direct or one of the insurance providers may ask for the person needing care to contact their doctor if there is a delay returning the medical report. By signing Section 1 below, authority is given to the Chief Medical Officer of Medicals Direct on receipt of a medical report, to forward a copy of it to the Chief Medical Officer of each insurance provider selected by you and your financial adviser.

Access to Medical Reports

The person needing care has three possible courses of action:

  1. Consent can be given without asking to see the doctor's report before it is sent to the Chief Medical Officer of Medicals Direct. The doctor will then send the report direct to the Chief Medical Officer of Medicals Direct.
  2. Consent can be given but the person needing care may ask to see the report before it is sent. The person needing care will have up to 21 days, from the date their doctor is notified they wish to see the report to make appropriate arrangements with their doctor. If contact is not made during this 21-day period, the doctor will be able to forward the report to the Chief Medical Officer of Medicals Direct without the care recipient seeing it in advance.
    3. The doctor can be asked to change the report if it is incorrect or misleading. If the doctor refuses, the person needing care or their legal representative may add their own comments to the report before it is sent to the Chief Medical Officer of Medicals Direct.
  3. Consent can be withheld but the insurance provider may not be able to offer terms for its Care Fees Payment Plan.

Whether or not a request has been made to see the report before it is sent, the doctor may be asked for a copy of it within six months of it being sent to the Chief Medical Officer at Medicals Direct. The doctor may make a reasonable charge for his services.

The doctor is entitled to withhold some or all of the information contained in the report if:

The medical report the doctor fills in requests the following information about the person needing care:

Their current and recent health

Their past health

The report does not request the doctor to reveal information about:

If the person needing care has any questions about their rights under the appropriate Act or questions relating to the process of getting, assessing or storing medical information, please write to:

Medicals Direct Screenings Ltd, ICP, Buckingham House, The Broadway, Stanmore, Middlesex, HA7 4EB.

Doctor's Details

The doctor's details are needed to obtain a medical report for the insurance providers so they can offer you terms for their plan. Some providers may also request a home report from the care provider.

Name and full postal address of the doctor who holds the medical records of the person needing care:

Doctor's name:

Address:

Telephone Number:

Fax Number (if available):

How long has the person needing care been registered with this doctor?

If less than six months, please give name and full postal address of previous doctor.

Doctor's name:

Address:

Telephone Number:

Fax Number (if available):

Your answers to the questions on this form will be used to assess your request by the selected insurance providers. All facts that are likely to influence the terms offered must be disclosed since part of the plan's benefit might be forfeited if you subsequently apply for a plan and relevant information is withheld. If you are unsure if a fact is likely to affect the insurance provider's decision, you should disclose it. Any changes to the answers given in this form before the plan comes into force must be notified to the insurance provider.

1. Declaration and Consent

In this section the terms "we", "our" and "us" would only apply if the applicant is not the person needing care or that person's legal representative acting on their behalf.

General

I, the applicant, confirm that I want those insurance providers selected in this form to provide me with offer terms for their Care Fees Payment Plan.

I/We* confirm that all declarations made in this form shall be deemed to have been made directly to the insurance providers selected on this form.

I/We* confirm that any copy of this form which is sent to Medicals Direct by my financial adviser and is subsequently forwarded to the insurance providers selected on this form, or any party involved in providing the report, shall be as valid as the original.

Use of personal data

I/We* understand that any information in this form will be held and used by each insurance provider, and by the insurance company's reinsurer (or any company acting on its behalf including Medicals Direct) to provide terms for its Care Fees Payment Plan.

I/We* understand that the information in this form will be used by the insurance provider to set up and administer its Care Fees Payment Plan if I/we* accept its terms. I/We* understand that my/our* details may be disclosed in confidence to other companies within each insurance provider's group or companies acting on their instructions (possibly to companies outside of the European Economic Area) for these purposes. By signing this Section of this form I/we* consent to such use of my/our* personal data.

Each insurance provider may disclose some of this information to companies within its group and other carefully selected organisations for marketing purposes to inform me/us* of any products and services which may be of interest.

I/we* do want an insurance provider to use the information supplied to let me/us* know about other products and services it offers.

I/we* do not want an insurance provider to use the information supplied to let me/us* know about other products and services it offers.

Please tick one of the boxes.

Health Information

I/We* declare that to the best of my/our* belief, all of the information provided in this form is true and complete in every particular, and I/we* have not withheld any material fact. (A material fact is one that an insurer would regard as likely to influence the terms and conditions it would offer for its Care Fees Payment Plan.)

I/We* agree to disclose to the insurance provider any occurrences affecting the health of the person needing care after this form is signed and before the Care Fees Payment Plan commences.

Consent to obtain medical reports

The person needing care (or their legal representative) declares they have read the important notes and information relating to their rights under the appropriate Act, which allows a doctor to provide a report from their medical records.

The person needing care (or their legal representative) agrees:

  1. that Medicals Direct and the insurance provider can ask any doctor who has treated him/her at any time for information about their health; and
  2. to that doctor providing the Chief Medical Officer of Medicals Direct and the insurance provider with the medical information requested; and
  3. that the Chief Medical Officer of Medicals Direct can forward the medical report to the Chief Medical Officer of each selected insurance provider.

I, the person needing care, do not want to see the report before it is sent to Medicals Direct

I, the person needing care, do want to see the report before it is sent to Medicals Direct

Please tick one of the boxes.

If the person needing care is unable to sign, the form should be signed by their personal representative. Please insert below the name and capacity of the person signing e.g. Mr John Smith by his Attorney Mr David Smith. Please enclose a certified copy of the appropriate authority with the completed questionnaire.

Full name of person signing:

Capacity of person signing:

Signature of person needing care or their legal representative acting on their behalf:



Date:

Signature of the Applicant (if you are not the person needing care or their legal representative):



Date:

A copy of this form is available on request.

Authority to my Financial Adviser

If the applicant is the legally appointed representative (e.g. an Attorney or as a court appointed deputy for the Court of Protection), the details of whom they are representing should be inserted above the signature.

Example: Mr John Smith by his Attorney Mr David Smith

I, the applicant, authorise my financial adviser to pass on a copy of this form to any selected insurance provider, and any third party working for a selected insurance provider, so that the selected insurance provider is able to offer me terms for its Care Fees Payment Plan.

Full Name of person signing:

Capacity of person signing:

Signed (Applicant):

Date: