Injury Benefit Application Form - IoMG Unified Scheme

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Part 6We need your consent to access information about your claimTo be completed by the applicant.Please read the following guidance about release of medical information beforecompleting this section, then sign and date the declaration and consent on the nextpage. Failure to provide information will result in your application being delayed orrejected.The PSPA may need additional reports from *your doctor, so that it can consider your application for Injury Benefits.(*This means any doctor who has treated you, or cared for you, or who has been involved in diagnosing your condition,and includes an Occupational Health Doctor). The PSPA may also need you to be examined by their independentmedical adviser.Access to Medical Reports Act 1988The Medical reports your doctor prepares for the PSPA or its medical advisers are subject to the ‘Access to MedicalReports Act 1988’. Under that Act you can either:• allow your doctor to send it straight to the PSPA without you seeing it first, or• ask to see the report before they send it to the PSPA, or• you can instruct the doctor not to send the report to the PSPA at all.Reports written by a doctor who has not been involved in your treatment, care or diagnosis or medical records thatalready exist are NOT subject to the Access to Medical Reports Act 1988.If you decide that a report requested by PSPA or it’s medical advisers can come straight to us without you seeing it first,you can still ask to see it at any time up to 6 months after we receive it.The 'Consent' you sign at the end of this section will tell your doctor whether you wish to see any report they preparebefore they send it to PSPA. If you decide you want to see the report before your doctor sends it, you have 21 days fromwhen the PSPA asks for the report to let your doctor know that you wish to see it. You can view the report for free, butyour doctor is entitled to charge you a reasonable fee if you want a copy for yourself. Your doctor can withhold all or partof the report from you. But, if they do so for professional medical reasons, they must tell you that they are doing so.If you think that the report your doctor has prepared is misleading or incorrect in any way, you can ask them in writing toamend it. Your doctor can refuse to amend the report, but if they do they will invite you to send a letter with yourcomments that they can attach to the report, before they send it to the PSPA.Release of medical information and examination by an independent doctorIn order to clarify or confirm certain aspects of your medical condition the PSPA may sometimes need to ask for othermedical, or relevant information (e.g. from your GP, Specialist or employer). We may also need you to be examined byits’ independent medical adviser. So that they understand what benefit you are claiming for we might need to pass any orall of the reports and medical or relevant information to them. The PSPA will also need to pass all the information itgathers to its Medical Advisers.If you do not agree to the release of reports or other information about your medical condition, the PSPA may be unableto consider your application for benefits.
Part 6 continuedYour consent under the Access to Medical Reports Act 1988I declare that I have read and understood the guidance about the Access to Medical Reports Act 1988.Please tick one of the following choices.I do not want to see any report from my doctor(s) before it is sent to the PSPA.I want to see any report from my doctor(s) before it is sent to the PSPA.Your consent for release of informationPlease tick one of the following choices.“I agree that for the purpose of considering my application, the PSPA and or their medical advisers canobtain information from my employer, DSC or any doctor or specialist who has been involved in my carethat is relevant to this claim, that the documents which were used for the assessment of my ill healthretirement application, and which are held by the PSPA, will be considered and all such information willbe made available to the PSPA Pensions’ administrators, their medical advisers, and where necessary, anindependent examining doctor.”“I do not agree that for the purpose of considering my application, the PSPA and or their medicaladvisers can obtain information from my employer, DSC or any doctor or specialist who has beeninvolved in my care that is relevant to this claim, that the documents which were used for theassessment of my ill health retirement application, and which are held by the PSPA, will be consideredand all such information will be made available to the PSPA Pensions’ administrators, their medicaladvisers, and where necessary, an independent examining doctor.”Please tick one of the following choices.Your signature:I agree to attend any medical examinations by an independent doctor if necessary.I do not agree to attend any medical examinations by an independent doctor.Print name:Home address:Home telephone number:Date:/ /Please check the form and make sure you have enclosed everything you want to send us.Send this form and all relevant papers to:PSPA Injury Benefits, Goldie House, 1-4 Goldie Terrace, Douglas ISLE OF MAN IM1 1EB
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Injury Benefit Application Form - IoMG Unified Scheme

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