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1 S21 – OCT 2008 Disability Allowance – Medical Alarm Costs Self-assessment form Please read this before you start CLIENT NUMBER Disability Allowance may be paid to cover the ongoing costs of a medical alarm if the need for a medical alarm is directly related to a person’s disability or personal health. The following questions are to assist you and Work and Income in making a decision as to whether a medical alarm is essential because of your disability or personal health need. Please complete all questions – if not applicable write N/A. Name 1. What is your name? First name(s) Surname or family name Self-assessment The information I have given is true and complete. Client’s signature Day Month Year Client statement 2. Who or what prompted you to obtain a medical alarm? 3. Have you discussed this with your doctor? No Yes 4. In the last 52 weeks have there been circumstances when you needed medical assistance but were unable to summon help? No Yes 5. Have you been assessed by a health professional as needing: Home help No Yes Meals on wheels No Yes Respite care No Yes 6. Are you able to: Garden No Yes Visit libraries/shops No Yes Move around without assistance No Yes Drive a car No Yes Participate in community activities No Yes 7. Do you currently have a medical alarm? No u Go to Question 8 Yes u Please provide details below: How long have you had the alarm? Years Months What company is your medical alarm supplied by? 8. After answering Questions 2–7, do you still consider that a medical alarm is essential for your independent living? No u You will not qualify to have the medical alarm costs included in your Disability Allowance. Yes u Please take this form to your doctor to have the Special Medical Certificate (over the page) completed. If someone has helped you to complete this form they need to fill in the ‘Helper’s Statement’ over the page. S21 – OCT 2008 2 Helper’s statement Helper’s name? First name(s) Surname or family name What is your address and phone number? How are you related to the applicant? I completed this form at the request of the applicant. The information I have given in this application is true and I have not left anything out. Helper’s signature Day Month Year Special medical certificate I have personally examined Client’s name and considered that: 1. The need for a medical alarm is ongoing and directly related to their disability/personal health need: No Yes 2. The medical alarm is essential to maintain independent living: No Yes 3. The need for a medical alarm should be reviewed in: 3 months 6 months 12 months Please print or stamp your full name, address, telephone number and Medical Council registration number. Registered Health Professional’s stamp or name and address Medical Council registration number Registered Health Professional’s signature Day Month Year Printed in New Zealand on paper sourced from well-managed sustainable forests using mineral oil free, soy-based vegetable inksTo be completed by any person who has helped the applicant complete this form. To be completed by a Registered Health Professional.
