DISCRETIONARY VOUCHER APPLICATION - GOS

PART 1 – TO BE COMPLETED BY THE APPLICANT

Section 1 – Personal Details:

Surname: / Forename:
Previous Surname: / Dateof Birth:
Full Address:
(including postcode)

Section 2 – Reason for Voucher Request

Loss/Breakage causing Major Hardship /  / Spare Pair / 
Over 16 – Loss/Breakage due to Illness or Disability /  / Non-tolerance / 

Section 3 – Entitlement

Please state your reason for possible entitlement to voucher – Evidence should be produced (complete giving certificate numbers as appropriate)

ENTITLEMENT CATEGORY (included in the award of) / EVIDENCE PRODUCED/CERTIFICATE NO
A / Income Support / 
B / Income Based Jobseekers Allowance / 
C / Income Related Employment Support Allowance / 
D / Universal Credit / 
E / I am named on a HC2 certificate / 
F / I am named on a HC3 certificate / 
G / I/my partner is named on a valid NHS Tax Credit Exemption / 
H / I/my partner receive(s) Pension Credit Guarantee Credit / 
I / I am a full time student aged 16, 17 or 18 years / 
Name and address of School/College/University currently attending:
Please give full details of the reason for your application, and any other supporting evidence that will enable us to consider your request. NB: A simple statement of lost/broken is insufficient and your application will not be considered. If you have broken your glasses you must provide a full detailed explanation of how the glasses were broken. Applications due to loss/crime must be accompanied by the relevant Police Loss Report or Police Crime Number – obtainable from your local Police Office.

Patient/Parent/Guardian’s Declaration:

I understand that if I give information that is incorrect or incomplete, action may be taken against me.

I declare that the information I have given is correct and complete.

There is no insurance or after sales service covering these glasses or contact lenses

I agree to a check of my entitlement to a NHS optical voucher being made with the Benefits Agency.

I agree to repay the voucher value if I am later found not to be entitled.

Signed: Date:

Voucher Details:

Voucher Type (please specify):
RIGHT / Sph / Cyl / Axis / Prism / Base / Sph / Cyl / Axis / Prism / Base / LEFT
DISTANCE
NEAR
Date of last eye examination: / dd / mm / yy
Parts: / Lens /  / Right /  / Left /  / Both / 
Frame /  / Front /  / Side /  / Whole / 
Supplements: / Prism:
Tint: / 

Voucher value appropriate to the above prescription: £ : p Total Claim: £ : p

Clinical Statement in Support of Application:

Please give below any clinical information to support the patient’s application (including visual acuitieswithout

Glasses)

I do/do not* support this application and declare that the information that I have given is correct and completed to the best of my knowledge and belief.

I confirm that the patient provided evidence for possible entitlement to a voucher: Yes/No* delete as appropriate

Optometrists’
Name(print): / List No:
Signature: / Date:

Practice Stamp:

FOR DIVISION USE ONLY

The application for the issue of a further optical voucher has been considered and is:

Approved  Not Approved 
Reason Approved/Not Approved
Date Received: / Ref Number: / Code/Voucher Issued
Authorised by:
Signature:
Designation: / Date

Completed forms should be returned to Melanie Meecham/Claire Piper, Primary Care, Larachan House, 9 Dochcarty Road, Dingwall, IV15 9UG