Docstoc

IN CONFIDENCE

Document Sample
IN CONFIDENCE Powered By Docstoc
					                                                                                                                HD 4/00


 PRINCIPAL CIVIL SERVICE PENSION SCHEME

 HEALTH DECLARATION
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.


Personal details


    Your title                Mr/Mrs/Miss/Ms                 Surname

    Other names

    Date of birth

    Address



                                                                         Postcode:

    Telephone no:


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


    Contact Name

    Contact Address



                                                                            Postcode:

    Telephone no:




    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
     give details)




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,
     including dates)




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,
     including dates)




Page 2                                              MEDICAL IN CONFIDENCE (after completion)
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,
      including dates)




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
      including dates)




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
      dates)



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:

   Name                                                                              Name

   Address                                                                           Address




   Postcode                                                                          Postcode

   Telephone                                                                         Telephone



Declaration
   I declare that the information I have given on this form is, to the best of my knowledge and belief, true
   and complete.

   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.


   Signed                                                                                                 Date

   Name

                      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.




   Page 4                                                                    MEDICAL IN CONFIDENCE (after completion)

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:11/20/2011
language:English
pages:4