Apply for Telecare

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1. Fair Processing Notice
  To find out how we will process and use personal information in connection with this request please see our Privacy Statements.
Why is a Telecare service required?
1. Please select one of the options*
  
  Due to a fall within the last year
  
  For safety and reassurance within the home
  
  To maintain independence
  
  Carer Support
  
  To assist a return home from hospital
2. Please specify planned discharge date
Who is completing this form?
1. We need to know who the Telecare Service is for
  
  I am applying for Telecare for myself
  
  I am applying for Telecare for someone else
2. When the service starts you will be charged £3.96 per week. Invoices will be sent every 4 weeks to the bill payer. Please note we will never contact the bill payer/service user by phone to query your charge or request payment. Who should the invoice be sent to
  
  Invoices should be sent to myself
  
  Invoices should be sent to someone else
3. When the service starts you will be charged £3.96 per week. Invoices will be sent every 4 weeks to the bill payer. Please note we will never contact the bill payer/service user by phone to query your charge or request payment. Who should the invoice be sent to
  
  Invoices should be sent to the person who requires Telecare
  
  Invoices should be sent to someone else
4. Details of Person to invoice
  1. First name
  2. Second name
  3. Second name
  4. Address
  5. Postcode
  6. Email address
    If you provide an email address then the invoice will be emailed to them
  7. Relationship
5. How did you find out about the Telecare Service?*

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