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The Personal Independence Payment (PIP) form is a crucial document designed to assess how an individual's health condition or disability impacts their daily living and mobility. This form requires personal details, including full name and National Insurance number, and emphasizes the importance of returning it promptly to avoid potential issues with the claim process. Within the accompanying Information Booklet, users will find guidance on completing the form accurately. This resource provides detailed explanations of the questions asked, offers advice on obtaining assistance, and illustrates examples of responses that can enhance the clarity of the individual's situation. It is essential for applicants to thoroughly describe their health conditions, medication, and the effect of these on their daily Life. Additionally, the PIP form encourages the submission of supplementary photocopied documents that can provide further evidence of how the applicant’s health challenges affect their ability to perform day-to-day activities. It’s important to note that any documents submitted will not be returned, so careful attention to detail is necessary. The form not only serves as a record of the applicant’s conditions but also facilitates communication with health professionals who may provide further insight into the individual’s needs.

Pip Example

Personal Independence Payment

How your disability affects you

Full name

National Insurance (NI) number

only

Please fill in this form and return it to us straightaway.

We’ve sent you an Information Booklet to help you complete the

form. In the Information Booklet we:

If you need to ask for more time to compl te this form please call suse on 0800 121 4433 (0800 121 4493 if using a t xtphon ).

• give advice on where you can get help to complete the f rm

• explain the questions we ask

• tell you how to answer the questions, and

• give you examples of other things you can tell us

If you don't return this form to us and we don't hear from you to ask for more time to complete t, we ay end your claim to PIP.

If you don't want to ont nue w th your claim and w n’t be etu ning this form, please call us on 0800 121 4433 (0800 121 4493 if using a textphone).

What you n d to do

Step 1

– Read through this form and the Inf

rma ion Booklet.

Step 2

– Fill in this form (in pen) to tell us h

for

w y ur health condition

 

or disability affects you.

 

tep 3

– Read and sign the declarati n n page 32.

tep 4

– Return the form to us with photocopies of any additional

Specimeninformation. Not

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Additional information to support your claim

As well as completing this form it is important that you help us to understand your needs by providing additional information. This should explain how your health condition or disability affects your daily life.

Do send information that shows how your health condition or disability affects you carrying out day-to-day activities.

Don’t send general information about your condition like fact sheets or information from the internet.

Only send us photocopies of information you already have available to you. We can’t return any documents to you.

There is more information, including examples of what to send us in the Information Booklet we sent you with this form.

only

Please put your name and National Insurance number

n the t p f

use

each document.

 

 

 

 

 

Specimen

 

Section 1 – About your health prof ssio

als

 

If we need additional information we may contact the h

alth professionals that upport you.

Q1 Tell us about the professional(s) best placed to advise s on how your health condition or d sab l ty affects you

For example, a GP, hospital doctor, spec alist nurse, community psychiatric nurse, occupational

therapist, physiotherapist, so

al worker, counsell

r, r supp t w

ker.

Name

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

Profession

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number including the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dialling code

 

 

 

 

 

 

When did you last see them?

 

 

 

 

 

 

/

/

 

 

(approximate date)

Not

 

 

 

 

 

 

 

 

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Section 1 – About your health professionals continued

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Profession

 

 

 

 

only

 

 

 

 

 

 

 

Phone number including the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dialling code

 

 

 

 

 

 

 

When did you last see them?

 

 

 

 

 

 

 

/

/

 

 

 

(approximate date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Po tcode

Profession

 

 

 

 

 

 

 

Phone number including the

 

 

for

use

dialling code

 

 

 

 

 

 

 

When did you last s th m?

 

/

/

 

 

 

(approximate dat )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

If you need to add more please c

ntinue at Q15 Additional information.

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Section 2 - About your health condition or disability

iUse page 7 of the Information Booklet to help you answer these questions.

Q2a - Tell us in the space below:

what your health conditions or disabilities are, and

approximately when each of these started

 

 

 

 

Health condition or disability

 

only

 

 

Approximate start date

 

Example: Diabetes

 

May 2010

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

for

 

We will ask you how your health ond t ons or disabilities affect h w useyou

carry out day-to-day a tivities in the rest of the

rm.

If you need to add more pl ase ontinue at Q15 Additional inf rmation.

Not

 

 

 

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Section 2 - About your health condition or disability continued

Q2b - Tell us about:

tablets or other medication you’re taking or will be taking and the dosage

any treatments you’re having or will be having, such as chemotherapy, physiotherapy or dialysis

any side effects these have on you

 

only

Specimen

use

Not

for

 

If you need to add more please continue at Q15 Additional information.

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Section 3 - How your health condition or disability affects your day-to-day life

Tell us in the rest of this form how your health conditions or disabilities affect your day-to-day activities.

Q3 - Preparing Food

i Use page 7 of the Information Booklet to help answer these questions.

Tell us about whether you can prepare a simple one course meal for one from fresh ingredients.

This includes things like:

 

 

 

 

 

 

food preparation such as peeling, chopping or opening packagi g, a d

safely cooking or heating food on a cooker hob or in a microwave oven

Tick the boxes that apply to you, then provide more informati

in the

Extra information box.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

Q3a - Do you need to use an aid

 

Yes

 

only

 

or appliance to prepare or

 

No

 

 

cook a simple meal?

 

 

 

 

Aids and appliances

 

 

Som tim s

 

 

 

include things like:

 

 

 

 

 

 

 

• perching stools,

 

 

 

 

 

 

 

lightweight pots and

 

 

 

 

 

 

pans, easy grip handles

 

 

for

 

 

• do they remind or

 

 

 

 

 

on utensils, single lever

 

 

 

 

 

 

arm taps and liqu d level

 

 

 

 

 

 

indicators

 

 

 

 

 

 

 

Q3b – Do you n

d h lp from

 

Yes

 

 

 

 

anoth r

rson to pr pare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

or cook a sim le m al?

 

No

 

 

 

 

By this we m an:

 

 

S me imes

 

 

 

motivate you to cook?

 

 

 

 

 

 

• do they plan the task f r

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

 

• do they supervise you?

 

 

 

 

 

 

• do they physically help

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

 

• do they prepare all your

 

 

 

 

 

 

food for you?

 

 

 

 

 

 

 

This includes help you

 

 

 

 

 

 

have, and help you need

 

 

 

 

 

 

but don’t get.

 

 

 

 

 

 

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Q3c - Extra information - Preparing Food

Tell us more about any difficulties you have when preparing and cooking food:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes to prepare and cook food

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

can you cook using an oven safely? If not, tell us why not

tell us about the aids or appliances you need to use to help you prepare and cook

 

food

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the help you need from another person when prepari g f od. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

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Q4 - Eating and drinking

iUse page 7 of the Information Booklet to help answer these questions.

Tell us about whether you can eat and drink.

This means:

remembering when to eat

cutting food into pieces

putting food and drink in your mouth, and

chewing and swallowing food and drink

 

 

 

 

 

 

only

Tick the boxes that apply to you, then provide more information in the

Extra information box.

 

 

 

 

 

 

Q4a – Do you need to use an aid

 

Yes

 

 

 

or appliance to eat and

 

No

 

 

 

drink?

 

 

 

 

 

 

Aids and appliances

 

 

Sometimes

 

 

 

 

 

 

include things like:

 

 

 

use

 

 

 

 

 

Specimen

 

 

• weighted cups, adapted

 

 

 

 

 

cutlery

 

 

 

 

 

 

 

Q4b – Do you use a feeding tube

 

Y s

 

 

 

or similar device to eat

 

No

 

 

 

or drink?

 

 

 

 

 

 

This means things l ke a

 

So eti es

 

 

feeding tube with a rate

 

 

for

 

limiting devi e as a

 

 

 

 

 

 

delivery system or feed

 

 

 

 

 

pump.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Q4c – Do you n

 

Not

 

 

 

d h lp from

 

Yes

 

 

 

anoth r

rson to at and

 

No

 

 

 

drink?

 

 

 

 

 

 

By this we mean:

 

 

S metimes

 

 

• do they remind you to eat

 

 

 

 

 

and drink?

 

 

 

 

 

 

• do they supervise you?

 

 

 

 

 

• do they physically help

 

 

 

 

 

you to eat and drink?

 

 

 

 

 

• do they help you manage

 

 

 

 

 

a feeding tube?

 

 

 

 

 

 

This includes help you have and help you need but don't get.

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Q4d - Extra information - Eating and drinking

Tell us more about any difficulties you have when eating and drinking:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the aids and appliances you need to use to help you eat and drink

tell us about the help you need from another person when eati g a d dri ki g. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

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Q5 – Managing treatments

iUse page 8 of the Information Booklet to help answer these questions

Tell us about whether you can monitor changes in your health condition, take medication or manage any treatments carried out at home. Monitoring changes include things like:

• monitoring blood sugar level, changes in mental state and pain levels

A home treatment includes things like:

 

 

only

 

 

 

 

• physiotherapy and home dialysis

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

 

Q5a – Do you need to use an aid

 

 

Yes

 

 

 

 

 

 

 

 

or appliance to monitor

 

 

No

 

 

 

 

 

 

 

 

your health conditions,

 

 

 

 

 

take medication or

 

 

 

Sometimes

 

use

 

 

 

 

 

 

 

 

 

Specimen

 

 

manage home

 

 

 

 

 

 

 

treatments?

 

 

 

 

 

 

 

For example, using a

 

 

 

 

 

 

 

Dosette Box for tablets.

 

 

 

 

Q5b – Do you need help from

 

Y s

 

 

 

another person to

 

 

 

No

for

 

monitor your health

 

 

 

 

 

 

conditions, take

 

 

 

So eti es

 

 

medication or manage

 

 

 

 

 

home treatments?

 

 

 

 

 

 

 

By this we m an:

 

 

 

 

 

 

 

• do th y r mind you to

 

 

 

 

take m dications and

 

 

 

 

treatm nt?

Not

 

 

 

 

 

 

 

 

 

 

• do th y su rvise you while you take your medication?

• do they physically help you take medication or manage treatments?

This includes help you have and help you need but don't get.

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Form Characteristics

Fact Name Description
Purpose The Personal Independence Payment (PIP) form is used to assess how a disability affects an individual's daily living and mobility.
Full Name Requirement Applicants must provide their full name as part of the identification process on the form.
National Insurance Number The form requests the National Insurance number, which is essential for verifying identity and eligibility.
Submission Deadline Completed forms must be returned promptly to avoid delays in processing or potential claims termination.
Information Booklet Each applicant receives an accompanying Information Booklet that explains the form's questions and provides guidance on completing it.
Health Professionals Section Applicants must list health professionals who can provide additional information regarding their condition's effects on daily activities.
Supporting Documents Photocopies of relevant supporting documents should be included, but applicants are advised against sending general information or fact sheets.
Declaration Signature A declaration must be signed to confirm the truthfulness of the information provided in the form.
Additional Information There is a section for additional comments, where applicants can further explain the impact of their health condition on daily life.
Governing Laws PIP is governed under the Welfare Reform Act 2012 and the subsequent regulations in each state related to disability benefits.

Guidelines on Utilizing Pip

The next steps involve carefully filling out the Personal Independence Payment (PIP) form to ensure your application is complete. To successfully complete this form, follow the outlined steps to accurately convey how your health condition or disability impacts your daily life.

  1. Read through the entire PIP form and the accompanying Information Booklet to understand what is being asked.
  2. Using a pen, fill in the form to describe how your health condition or disability affects your everyday activities.
  3. Locate page 32 and read the declaration. Make sure to sign it to confirm that the information you provided is accurate.
  4. Compile any necessary additional information that supports your claim and include photocopies of these documents. Remember to only send photocopies, as originals cannot be returned.
  5. Clearly write your name and National Insurance number on the top of each document for identification.
  6. Submit the completed form along with your additional information as promptly as possible to avoid delays in processing your claim.

What You Should Know About This Form

What is the Personal Independence Payment (PIP) form used for?

The Personal Independence Payment (PIP) form is designed for individuals with disabilities or health conditions to explain how these affect their daily lives. It helps the relevant authorities assess eligibility for financial support. When completed accurately, the form provides crucial information that clarifies the impact of one’s condition on daily activities.

How do I fill out the PIP form properly?

To fill out the PIP form effectively, start by reading the Information Booklet that accompanies the form. This booklet provides guidance on the questions asked and offers examples that can help you frame your answers. It’s important to detail how your health condition impacts your daily life. Use a pen for legible handwriting, and remember to sign the declaration at the end. Additionally, photocopies of documents that support your claim, such as medical history, should be included.

What kind of additional information should I provide?

When submitting the PIP form, it is beneficial to include specific information that illustrates how your condition affects your day-to-day activities. This could be letters from healthcare professionals, reports from therapists, or records of medications. General information or fact sheets about your condition, however, should not be submitted. Make sure to send photocopies, as original documents cannot be returned.

What happens if I don’t return the form on time?

If you do not return the PIP form promptly and do not request an extension, there is a risk that your claim may be denied. It is crucial to either send the completed form within the specified timeframe or contact the authorities to ask for more time. Failure to communicate can result in the discontinuation of benefits you may be entitled to.

How do I include information about my healthcare professionals?

The form includes a section dedicated to detailing your healthcare professionals. You should provide names, contact details, and the type of profession for medical practitioners familiar with your health condition. For instance, listing specialists such as your GP, hospital doctor, or therapists, and including when you last consulted them will assist in providing context for your claim.

Can I get help to complete the PIP form?

Yes, assistance is available for completing the PIP form. The Information Booklet sent with the form contains advice on where to seek help. Additionally, if you need further clarification, you can contact the provided helpline. It’s advisable to reach out for help if you encounter difficulties understanding or completing any part of the form.

Common mistakes

Completing the Personal Independence Payment (PIP) form is crucial for individuals seeking assistance. However, many make common mistakes that can jeopardize their claims. One frequent error is omitting important personal details. People sometimes forget to provide their full name or National Insurance number, which can delay the processing of their application.

Another common mistake is failing to accurately describe how their health condition affects daily life. This section is crucial, as it guides decision-makers on the level of support needed. Individuals often give generic descriptions of their health conditions instead of detailing the specific challenges they face in everyday tasks.

A third mistake involves neglecting to include additional supporting documents. The form specifically requests that claimants send photocopies of existing information, such as medical reports or letters from health professionals. Sending irrelevant information, like internet printouts, can also hinder the application process.

Many people do not take advantage of the resources provided in the Information Booklet that accompanies the form. This booklet outlines how to answer questions effectively and provides examples. Ignoring this guidance can lead to incomplete or unclear responses.

Moreover, some applicants fail to review their completed forms before submission. Mistakes in spelling, clarity, or coherence can change the nature of the information presented. Taking time to proofread ensures that the application accurately reflects the applicant's situation.

Lastly, individuals sometimes wait too long to return the form or forget to ask for an extension if needed. The PIP process is time-sensitive, and delays could result in losing access to vital support. If more time is needed, it’s important to reach out to the designated contact numbers provided.

Documents used along the form

When applying for Personal Independence Payment (PIP), there are several additional documents and forms that can help support your claim. These documents can provide more context about your health conditions and how they affect your daily life. Below is a list of some commonly used forms and documents that may accompany the PIP form.

  • Disability Living Allowance (DLA) Application Form: This form is for those who are transitioning from DLA to PIP or those applying for DLA. It gathers similar information about how a disability impacts everyday life, providing background for the assessment process.
  • Supporting Medical Evidence: This document consists of reports and letters from healthcare professionals detailing your health condition. It should outline your diagnosis, treatment, and any limitations caused by your condition. This information can significantly strengthen your claim.
  • Personal Statement: A firsthand account of how your disability affects your life, the personal statement allows you to paint a detailed picture. It can include descriptions of daily challenges, emotional impacts, and the need for assistance.
  • Care Plans: If you have a care plan from a healthcare provider or social worker, this document summarizes your needs, prognosis, and any support you receive. It helps illustrate the level of assistance required in your daily activities.
  • Attendance Records: If you regularly see healthcare professionals for treatments, maintaining a log or records of these appointments can be beneficial. This helps to demonstrate the ongoing nature of your condition and the need for continuous support.

Submitting these additional documents along with the PIP form can enhance your application by providing comprehensive insights into your situation. Each of these forms plays a role in building a clearer understanding of your unique circumstances, which is crucial for the review process.

Similar forms

  • Social Security Disability Insurance (SSDI) Application: Similar to the Pip form, the SSDI application requires individuals to provide detailed information about their disabilities and how these conditions impact their ability to work. Each application processes needs assessments of daily living challenges.
  • Supplemental Security Income (SSI) Application: Like the Pip form, the SSI application assesses how disabilities affect day-to-day activities. Both forms gather financial information to determine eligibility for support.
  • Americans with Disabilities Act (ADA) Request for Accommodations: This document requests specific accommodations based on a person’s disability. Similar to the Pip form, it necessitates an explanation of how the disability affects daily functioning.
  • Veterans Affairs (VA) Disability Claim: The VA disability claim form requires veterans to articulate how their service-related disabilities affect their daily lives. This mirrors the Pip form’s requirement to outline the impact of disability on a person's life.
  • Long-Term Disability Insurance Claim: Similar to the Pip form, this type of claim necessitates a detailed account of the applicant's condition and how it hinders their ability to perform job-related tasks.
  • Occupational Safety and Health Administration (OSHA) Incident Report: This document may involve reporting an injury or illness and how it impacts an individual’s work abilities. Like the Pip form, it requires crucial details about the condition and its effects.
  • Medicaid Long-Term Care Application: This application requires individuals to explain their health needs and how they affect daily tasks, paralleling the Pip form's approach to understanding the individual's specific situation.

Dos and Don'ts

When filling out the PIP form, there are important dos and don'ts to keep in mind. This can help ensure your application is completed correctly and submitted on time.

  • Do read through the form and the accompanying Information Booklet carefully before starting.
  • Do fill out the form using a pen to ensure legibility.
  • Do provide specific examples of how your health condition or disability affects your daily life.
  • Do include photocopies of additional information that supports your claim.
  • Do sign the declaration at the end of the form.
  • Don't send general information about your condition, like fact sheets from the internet.
  • Don't submit original documents, as the office cannot return them to you.
  • Don't delay in returning the form; send it back as soon as possible.
  • Don't forget to include your name and National Insurance number on each document you send.
  • Don't hesitate to ask for more time if you need it by calling the provided phone numbers.

Keeping these tips in mind can make completing the PIP form a smoother process. Good luck with your application!

Misconceptions

Misconceptions about the Personal Independence Payment (PIP) form can lead to confusion and errors during the application process. Here are four common misconceptions:

  • PIP is automatically granted if someone has a disability. Many believe that having a disability qualifies one for PIP. In reality, the approval depends on how the condition affects daily life. The form focuses on specific ways an individual's health impacts their day-to-day activities.
  • You must return the form immediately without any additional information. Some think that submitting the form without extra documentation is sufficient. While the form is important, providing additional information can greatly support the claim. It allows you to elaborate on how your health condition affects your daily activities.
  • If you miss the deadline, you cannot get an extension. Many feel that a missed deadline means losing the chance to apply. However, you can request more time to complete the form by contacting the appropriate phone number provided. Ensure you reach out for assistance before the deadline passes.
  • Your health professionals will automatically provide information for you. Some applicants assume their doctors or therapists will relay information on their behalf. It's necessary to include the contact details of your health professionals in the form but be prepared to provide specific insights into your situation yourself. The PIP assessors may reach out, but they rely on your input as well.

Key takeaways

Filling out the Pip form is an important process in determining your eligibility for Personal Independence Payment. Here are some key takeaways to keep in mind:

  • Read the Information Booklet thoroughly before completing the form. It will guide you through the questions and offer important advice.
  • Provide detailed information about how your health condition or disability impacts your daily activities. Focus on specific examples rather than general information.
  • Return the form promptly, along with any photocopies of supporting documents. Remember, once submitted, documents cannot be returned.
  • If you need more time, reach out to the hotline provided. Clear communication can help avoid complications with your claim.