PRINCIPAL CIVIL SERVICE PENSION SCHEME
The Principal Civil Service Pension Scheme (PCSPS) provides generous benefits should a member’s health break
down to the extent that he/she is permanently incapable of continuing at work. In order to satisfy the health standards
of the Scheme and gain full membership of the PCSPS you must provide full details of your current and past health.
The PCSPS may then take medical and, if necessary, actuarial advice to determine whether you can be accepted for
ill-health benefits in addition to normal retirement pension and death-in-service benefits.
Please complete the form and return it as directed. The completed form will be inspected only if you are
recommended for pensionable appointment. The health of each applicant is considered individually, and no decision
to offer less than full benefits on health grounds will be made without professional medical advice. However, if you do
not complete and return the form you will automatically be excluded from the ill-health benefit provisions.
It is in your own interests to complete the form as fully as possible. If you give any information which you know is false
— or if you withhold any information — you may lose your rights to certain pension benefits.
Your title Mr/Mrs/Miss/Ms Surname
Date of birth
To be completed by recruiting organisation
Job title of post applied for:
(Job description to be attached to this form)
Name of Dept/Agency/NDPB
Department Code Location Code
If codes are not known they may be obtained from BMI
MEDICAL IN CONFIDENCE (after completion) Page 1
Section 1 – General Medical History
1. Are you currently in poor health? (if yes, give details) Yes No
2. Have you ever been retired on grounds of ill-health (medically retired) from any Yes No
employment? (if yes, give details, including dates)
3. Have you ever been refused life insurance or offered cover on special terms Yes No
because of your health? (if yes, give details, including dates)
4. Have you ever left, or been denied, employment because of your health? (if yes, Yes No
give details, including dates)
5. Have you ever left, or been denied, employment in the Civil Service on grounds of Yes No
ill health or of unsatisfactory attendance? (if yes, give details, including dates)
Section 2 – Specific Medical History
6. Are you under medical treatment or observation (including counselling)? (if yes, Yes No
7. Are you currently taking any medicines, pills (other than contraceptive pills), tablets, Yes No
inhalers or injections? (If yes, give details)
8. Have you ever had problems with your heart or circulatory system? (eg Heart Yes No
attack, angina, stroke, thrombosis or high blood pressure) (if yes, give details,
9. Have you ever had problems with your bones, joints or muscles? (eg arthritis, Yes No
rheumatism, slipped disc, tenosynovitis, fibromyalgia, ME, etc) (if yes, give details,
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10. Have you ever had mental ill health (eg nervous breakdown, anxiety, depression, Yes No
schizophrenia, eating disorder) or alcohol or drug problem? (if yes, give details,
11. Have you ever had any neurological disorder? (eg paralysis, multiple sclerosis, Yes No
muscular distrophy, etc) (if yes, give details, including dates)
12. Have you ever had any respiratory or lung disorder? (eg asthma, bronchitis, cystic Yes No
fibrosis etc) (if yes, give details, including dates)
13. Have you ever had any stomach or bowel disorder? (eg peptic ulcer, irritable Yes No
bowel, colitis etc) (if yes, give details, including dates)
14. Have you ever had kidney, bladder or reproductive disorder? (eg renal failure, Yes No
polyps etc) (if yes, give details, including dates)
15. Have you ever had any endocrine, gland or hormone problems? (eg thyroid, Yes No
diabetes, etc) (if yes, give details, including dates)
16. Have you ever had any chronic infection? (eg hepatitis, jaundice, HIV, Yes No
tuberculosis, etc) (if yes, give details, including dates)
17. Have you ever had any form of cancer, tumour or malignancy? (if yes, give details, Yes No
18. Have you ever had treatment in hospital, any operation or serious accident ? Yes No
(appendicectomy, tonsillectomy, squint surgery, caesarean section, vasectomy or
the removal of wisdom teeth need not be declared) (if yes, give details including
19. Have you ever had any other significant illness? (Colds, coughs etc and normal Yes No
childhood illnesses need not be disclosed unless they have led to complications) (if
yes, give details, including dates)
MEDICAL IN CONFIDENCE (after completion) Page 3
Consent to release personal medical information
May our medical adviser approach your GP and, if necessary, your hospital Yes No
specialist for medical information for the purposes of assessing your eligibility for
entry to the full benefits of the Civil Service Pension Scheme?
Under the terms of the Access to Medical Reports Act 1988 , do you See before supply
wish to see a report about your health before it is supplied by your GP or
specialist, or may this be forwarded directly to the PCSPS medical Forward to PCSPS
adviser? medical adviser
† - please read carefully the terms of the Access to Medical Reports Act 1988 below
Please give details of your family doctor: Please give details of your specialist:
I declare that the information I have given on this form is, to the best of my knowledge and belief, true
I understand that I may be required to attend a medical examination
I understand that all medical information will be held in medical confidence and that advice given to
pension scheme administrators about my health will be in general terms only.
Completed forms should be forwarded by PCSPS employers to:
BMI Health Services, Unit 1 Greyfriars, 10 Queen Victoria Road, COVENTRY CV1 3PJ
Access to Medical Reports Act 1988
You may withhold your consent for the medical adviser to the PCSPS to apply to your doctor/hospital specialist for medical information. If you give
your consent, you may see any report compiled by your doctor/specialist before it is supplied to us.
You have calendar 21 days from the date of the letter notifying you that a report has been requested in which to ask your doctor/specialist for
access to the report. If you do request access, your doctor/specialist will advise you whether, for professional medical reasons, any part of the
report is being withheld and will not send the report to our medical adviser until you give your consent.
If you regard any part of the report incorrect or misleading, you can ask for it to be amended. Your doctor/specialist is not obliged to change the
report, but where they choose not to make any amendment, they will invite you to prepare a written statement on the disputed information for
attachment to the report.
Subject to the provisions of the Act, you have the right to see the report for up to 6 months after it is sent to our medical adviser.
If your doctor/specialist gives you a copy of the report at your request, they may level a reasonable fee to cover any costs incurred.
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