Apply for a Blue Badge - Torbay and South Devon NHS ... · applicable). Along with a recent passport style photograph of the applicant’s face. The local authority may refuse to

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Apply for a Blue Badge Apply for yourself, someone else or an organisation. A Blue Badge costs up to £10 in England. If you wish to pay by debit card please insert your card details on page 25. We do not except credit cards.

You’ll need to provide proof of identity, address and benefit (if applicable). Along with a recent passport style photograph of the applicant’s face.

The local authority may refuse to issue a badge if you do not provide adequate evidence that you meet the eligibility criteria.

Visit: gov.uk/apply-blue-badge

Please only send back relevant pages of the application to: Blue Badge Castle Circus Health Centre Abbey Road Torquay TQ2 5YH Renewal Date :

Who are you applying for?

Myself (The badge is for you)

Someone else (A relative or somebody you care for)

Fill in the answers and sign the form on their behalf. Where the form says “you”, it is referring to the applicant.

An organisation (Which transports disabled people)

Please refer to guidance notes

If you’re applying for somebody else, we’ll ask for your name and your relationship to the applicant.

For organisations, you only need to fill in the organisation section.

Do you already have a Blue Badge?

Yes Enter the badge number (6 digits)

No What is your preferred way to communicate? Letter Telephone Email Other

if other please state.

If you don’t know the badge number, leave it blank and your local authority should be able to find the badge using your details.

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Full name (First name and Last name)

Surname at birth (if different)

Yes, enter full name at birth

Date of birth

Should be the full name of the person the badge is for.

National insurance number

This helps us to find your details if you call up about your application.

Current address

Personal details of Applicant For organisations, go straight to section F

Postcode:

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Email address (optional)

This will be used for updates about the application.

Main phone number

Who should be contacted about this application? (If you’re the contact, put your full name and phone number here)

Your relationship to the applicant

Are you a carer for the applicant? Yes No

Family, Carers and Friends

If you require a help, information and advice please call Signposts for Carers on 01803 666620 or email: [email protected] OR

Each Torbay GP has a Carers Support Worker – please contact your surgery.

Personal details of Applicant

If you are applying on behalf of somebody else

mailto:[email protected]

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Please provide a copy of photo identity and permanent address? Please provide photo identity – one item from list one below.

List One

Birth or adoption certificate

Marriage / Civil partnership / Dissolution or Divorce certificate

Passport

Driving licence Other Please provide one item from list two below as proof of permanent address. List Two Utility Bill Council Tax Bill/Statement Prescription Benefit Award Child Benefit (if applicant is a child)

Do not send original documents.

Recent photograph of the applicant

You’ll need a photo to be printed on the back of the Blue Badge. The requirements are similar to a passport photo.

Make sure it:

- Has a plain, light, background - Includes face and shoulders - Shows the face clearly

It’s best to get somebody else to take the photo.

The photo should have the applicant’s name and a signature on the back.

Identity and Address Verification

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You may automatically qualify for a Blue Badge if you either:

• Are severely sight impaired (blind) • Received 8 or more points in the “moving around” part or 10

points in the “planning and following journeys” part in descriptor E only of a mobility assessment for Personal Independence Payment (PIP)

• Receive the higher rate of the mobility component for Disability Living Allowance

• Receive the War Pensioners’ Mobility Supplement • Receive a qualifying award under the Armed Forces

Compensation Scheme

If none of these apply to you, go to Section B. Otherwise, you should continue to complete section A below.

Unless you are registered as severely sight impaired (blind), you will need to attach a copy of the proof of your benefit to this application.

PIP Descriptor E in Planning and following a journey is, ‘You cannot undertake any journey because it would cause overwhelming psychological distress’

Are you registered as severely sight impaired (blind) and do you give us permission to check the register at the local authority?

Yes Enclose a copy of your Certificate of Vision Impairment (CVI)

No (Please complete section B1, B2, C or D relevant to your conditions) You will need to apply under discretionary not automatic criteria.

If you are not registered as severely sight impaired (blind) and you would like to be, let the local authority know. The local authority will be able to add you to the register if you have your Certificate of Vision Impairment.

Were you awarded the higher rate of the mobility component?

Yes If your award has an end date, enter the end date

No

You should answer the questions in Section B1, B2, C or D relevant to your conditions. You will need to apply under discretionary not automatic criteria.

If you are in receipt of the higher rate of the mobility component, you need to attach a copy of the letter from DWP, dated within the last 12 months, showing your current address. This certificate of entitlement should confirm your mobility rating.

Make sure you send a copy of the award letter with this application.

Section A – Automatic Criteria

Severely sight impaired (blind)

Disability Living Allowance (DLA)

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Did you score 8 points or more in the “moving around” part of the mobility assessment?

Yes How many points were scored?

If your award has an end date, enter the end date

No

Answer the next question under “PIP”

If you did score 8 points or more in the “moving around” part of the mobility assessment, you need to attach a copy of every page from the award letter from DWP. It should show your entitlement to PIP, assessment scores (including the mobility scores). Must be dated in the last 12 months and show your current address.

Make sure you send a copy of all of the pages from the award letter with this application.

Section A – Automatic Criteria Personal Independence Payment (PIP) – Applying under a

physical disability.

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1) Did you score 10 points in the “planning and following a

journey” part of the mobility assessment? 2) Was it 10 points in, ‘You cannot undertake any journey

because it would cause overwhelming psychological distress’?

Yes to both 1 + 2 questions. If your award has an end date, enter the end date

No

You do meet the criteria for an automatic Blue Badge. You should answer the questions in Section B – Discretionary.

If you did score the 10 points outlined above in the “planning and following journeys” part of the assessment, you need to attach a copy of every page from the award letter from DWP. It should show your entitlement to PIP, assessment scores (including the mobility scores) and must show your current address and be dated within the last 12 months.

Make sure you send a copy of all of the pages from the award letter with this application.

Have you received a lump sum payment within tariff levels 1 to 8 of the scheme and have you been certified as having a lasting (enduring) and substantial disability?

Yes Enclose the original letter from Service Personnel and Veterans Agency (SPVA) as proof.

No


You must enclose the copy of your letter as proof of entitlement.

Section A – Automatic Criteria Personal Independence Payment (PIP) – Applying under a

hidden/non—physical disability.

Armed Forces Compensation Scheme

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Do you receive the War Pensioners’ Mobility Supplement?

Yes If your award has an end date, enter the end date

No


You must enclose a copy of your letter as proof of entitlement.

Section A – Automatic Criteria War Pensioners’ Mobility Supplement

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If you answered “yes” to any of the questions in section A, go straight to section E.

What is the main reason you need a Blue Badge?

I have a condition or disability which means I cannot walk or find walking very difficult (Please complete section B1 below).

I have an invisible (hidden) condition or disability, causing me to severely struggle with journeys between a vehicle and my destination (Please complete section B2 below).

I have a severe disability in both arms and drive regularly, but cannot operate pay and display parking machines (Please complete section C below).

I am a child under the age of 3 and require heavy/bulky medical equipment or a car nearby to manage my condition or disability (Please complete section D below).

I have a terminal illness, and have DS1500 form or have been referred from Lodge (Please contact the Blue Badge team prior to completing the application for further guidance).

Remember, when we are referring to “you” this is the applicant. If you’re applying for somebody else, answer the questions on their behalf.

Section B – Discretionary Criteria

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Name any health conditions or disabilities that affect your walking (Try to use the correct medical terms, if you know them)

Have you seen a healthcare professional for any falls in the last 12 months?

Yes No How does your health condition make walking difficult for you?

Excessive pain / Poor Balance / Falls (how many in the last 12 months) Describe the pain you get when walking. How severe is the pain? Describe your walking. Describe how you fall.

Be as descriptive as possible, but we’ll ask you some more questions after this about how your walking is affected and things like medication.

Only fill in the extra text-boxes if you’ve ticked the checkbox.

Section B1 – Physical Disability

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Please tick any statements that apply to you. I am able to walk well, including recreational walks. I am able to walk around the supermarket to do my own shopping. I am able to walk and can use public transport for some of my local trips. I am able to walk but struggle with long distances or hills. I am able to walk, but get breathless if I walk for more than a few minutes. I am able to walk but use a wheelchair for longer trips outside the home. I am able to walk around my home, but am unable to climb the stairs.

If you become Breathless, please answer this section below.

When do you get breathless? (You can choose more than one)

Walking up a slight hill

Trying to keep up with others on level ground

Walking on level ground at my own pace

Getting dressed or trying to leave my home

Other Describe when you get breathless

Also known as shortness of breath, this could be described as an intense tightening in the chest, or a feeling of suffocation.


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Please tick the walking aid(s) you regularly use:

Wheelchair: Manual □ Powered □ Walking stick □ Crutches □ Walking frame □ Four wheeled walker Artificial limb(s) □ Require help of another person to assist walking □ Other □ None □ Mobility Scooter Please give details below (include if this aid was privately brought or a health professional prescribed (name and profession)):

How long can you walk for without stopping? (If you listed an aid, then your answer should be when using that aid)

I can't walk at all

Less than a minute

Between 1 and 5 minutes

Between 5 and 10 minutes

More than 10 minutes

“Stopping” could be to take a rest or to catch your breath.

Only tick one.

Please provide a specific destination you are able to walk to from home e.g. home to local shop.

How long does it take you? (For example, 8 minutes)

For example, “from my home to Tesco” or “from my home to No. 36 on my street”

If you use an aid to get around, then your answer should be whilst using that aid


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Are you expecting to have surgery for your condition?

Yes No If yes, please give details below

Are you expecting your condition to improve following surgery, medication or treatment?

Yes No (why, please explain below).

You can now go to: Section E – Medication and Healthcare professionals


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Do you have an invisible (hidden) condition or disability, causing you to severely struggle with journeys?

Yes Continue answering the questions in this section

No

Go to Section E.


What affects you taking a journey? (Tick all that apply)

I am a risk to myself or others near vehicles, in traffic or car parks When are you a risk?

Sometimes Regularly Every journey What journeys does this apply to?

Unfamiliar journeys Every journey

Please give an example of when you have been a risk near vehicles, in traffic or car parks

If some, or most, of these do not apply to you, please use the free text boxes to explain what affects you.

Section B2 – Invisible (hidden) disabilities

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What affects you taking a journey? (Tick all that apply)

I find it difficult or impossible to control my actions and lack awareness of the impact they could have on others. How often does this happen?

Sometimes Regularly Every journey

Please describe the kinds of incidents that have happened or are likely to happen on journeys in traffic /car parks.

I regularly have intense responses to overwhelming situations causing temporary loss of behavioural control (meltdown). How often does this happen?


Please give examples of the situations that cause the meltdowns.

If some, or most, of these do not apply to you, please use the free text boxes to explain what affects you.


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I can become extremely anxious or fearful of public/open spaces When do you become extremely anxious/fearful?


Please describe the levels of anxiety and where they occur.

Something else (provide details below).

How would a Blue Badge improve taking a journey between a vehicle and the destination for you? (Please give details below)


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Does having a familiar person (Family, Friend, and Carer) present assist in improving your condition? Yes (Please give details below) No

What are your coping strategies? How effective are your coping strategies? (please give details below)



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Do you have a disability in both arms?


No

Go to Section E


Do you drive regularly?


No

Name any health conditions or disabilities that affect your arms (Try to use the correct medical terms, if you know them)

Section C – Disability that affects both arms

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Do you struggle to operate parking machines?

Yes Describe how you struggle to operate parking machines

No (Go to section E)

Do you drive an adapted vehicle? Yes Describe how it has been adapted for you. You should also attach copies of insurance details which verify this.

No

Attach copies of your insurance details as supporting documents.

Section C – Disability that affects both arms

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This section is for people applying on behalf of a child that is under 3 years old.

Are you applying for a child under 3 years old?


No

Go to Section E.

Which of these applies to the child under 3?

They need to be accompanied by bulky medical equipment

They need to be near a vehicle to receive or be taken for treatment

Neither of these

Name any health conditions or disabilities that affect the child (Try to use the correct medical terms, if you know them / Please list equipment required / Please describe treatment potentially needed in the car.)

You should enclose a letter from any healthcare professionals that are involved in the child’s treatments, which confirms the details of the condition.

Section D – Children under 3 years old

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This section is for if you have answered any of the questions in sections B, C or D. Otherwise, go to Section G. Do you take any medication or are you undergoing any treatments for your condition?

Yes Please provide a recent prescription (not older than 2 months) and a list of any over the counter medication and/or treatments in the space below.

No

Go to Healthcare professionals below


Please provide a recent prescription (not older than 2 months) and a list of any over the counter medication and/or treatments.

Section E – Medication and Healthcare Professionals

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Are there professionals we could contact that can provide further evidence if needed? (For example Consultants, Specialist Nurses, Occupational Therapist and Physiotherapist).

Yes, add their details below

No

(Go to section G)

Name and role of the professional

(This cannot only be your GP)

Where do they work?

(Include contact details if possible)

Healthcare professionals

Healthcare professionals

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Does your organisation care for people who need a Blue Badge?

Yes

No

Does your organisation transport the people you care for?

Yes

No

If you answer “No” to either of these questions, it is unlikely your organisation is eligible for a Blue Badge.

How many people do you care for and of those how many would meet the criteria?

Number cared for. Number eligible.

What’s the name of your organisation?

What is your Charity registration number (if applicable)?

Postal address (This is where the badge will be posted to)

Section F – Organisational badges

Postcode:

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Who should be contacted about this application? (If you’re the contact, put your full name here)

Email address (optional)

This will be used for updates about the application.

Main phone number

Vehicle registration number How often is the vehicle used?

Section F – Organisational badges

List the vehicles the badge will be used in

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By submitting this application you agree that:

• you have read and understand the rules for using a Blue Badge • the details provided are complete and accurate • you won't hold more than one Blue Badge at any time • you will tell your local authority about any changes that may affect

your eligibility You also agree that your local authority may:

• contact you if there are any issues with this application or to prevent badge misuse

• if required, arrange a phone-based or in-person assessment for you • check your eligibility with the information they hold • suggest other benefits or services that you may be eligible for • We will check any care records which we hold to verify information

for those who do not meet the automatic criteria in section A.

I agree to this declaration and give my informed consent.

Signed

Date of signature

Read the declaration carefully and only sign it once you are clear.

Section G – Declaration/Consent

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Following a review of the cost of administering the scheme, including centralised printing of Blue Badges and compliance of the scheme, it has been necessary for Torbay and South Devon NHS Foundation Trust and Torbay Council to set an administration charge for the issuing of Blue Badges. This charge has been set at £10.00. Payment by cheque - made payable to TSDFT If you wish to pay by DEBIT card complete the following section (we cannot accept credit cards) CARD NUMBER EXPIRY DATE EXPIRY DATE Name on card: ______________________________________ SECURITY CODE (Last 3 digits on back of card) Please note: Payment will only be taken at the process stage of your application. Automatic Criteria (Section A) - can take up to 2 weeks to process. Discretionary Criteria (Section B) - can take up to 10-12 weeks to process- cheque will be returned to unsuccessful applicant.

Section H – Debit Card Payments

Documents

Apply for a Blue Badge - Torbay and South Devon NHS ... · applicable). Along with a recent passport style photograph of the applicant’s face. The local authority may refuse to