Mobile Work e-mail Name and Title Relationship Address Emergency contact 3 Home Mobile Contact Details Work e-mail Please provide details on how we can access the property in an emergency: A key safe is required and will be provided where required to enable mobile responder service/emergency services access to the property in an emergency. Is a key safe in place? Yes No If Yes, the key safe number will be securely requested at a later date If the Telecare service is provided to anyone that is currently receiving care and support through Wolverhampton Council, the Telecare service would form part of an assessed charge; Telecare is also provided free of charge for the duration of any reablement support. The Service is provided free of charge to people in receipt of at least one of the following benefits only without additional disability benefits (i.e. Attendance Allowance/Disability Living Allowance/Personal Independence Payment). PLEASE TICK ANY BENEFITS YOU ARE IN RECEIPT OF :- Pension Credit (Guaranteed) Attendance Allowance (AA) • Income Support Disability Living Allowance (DLA) • Income-related ESA Personal Independent Payment (PIP) • Universal Credit (below established threshold) Maximum Housing Benefit Maximum Council Tax Reduction Form DS1500 (prognosis of less than six months to live) If an individual is in receipt of Attendance Allowance/DLA/PIP, the standard charge will be applied for the relevant level of service (irrespective of whether the individual is in receipt of the benefits listed above or not) All people living in Wolverhampton can access the Telecare Service for a weekly charge.
Mobile Work e-mail Emergency contact 3 Name and Title Relationship Address Contact Details Home Mobile Work e-mail Please provide details on how we can access the property in an emergency: A key safe is required and will be provided where required to enable mobile responder service/emergency services access to the property in an emergency. Is a key safe in place? Yes No If Yes, the key safe number will be securely requested at a later date If the Telecare service is provided to anyone that is currently receiving care and support through Wolverhampton Council, the Telecare service would form part of an assessed charge; Telecare is also provided free of charge for the duration of any reablement support. The Service is provided free of charge to people in receipt of at least one of the following benefits only without additional disability benefits (i.e. Attendance Allowance/Disability Living Allowance/Personal Independence Payment). PLEASE TICK ANY BENEFITS YOU ARE IN RECEIPT OF :- Pension Credit (Guaranteed) • Attendance Allowance (AA) Income Support • Disability Living Allowance (DLA) Income-related ESA • Personal Independent Payment (PIP) Universal Credit (below established threshold) Maximum Housing Benefit Maximum Council Tax Reduction Form DS1500 (prognosis of less than six months to live) If an individual is in receipt of Attendance Allowance/DLA/PIP, the standard charge will be applied for the relevant level of service (irrespective of whether the individual is in receipt of the benefits listed above or not) All people living in Wolverhampton can access the Telecare Service for a weekly charge.
telecare_application_form_v1_3_5.docx