Name
Address
Date
Dear
Client Charging Notification & Declaration
Paying for Care and Support
Part A
If you are assessed as having an eligible care or support need by
Worcestershire Adult Services and Health, in accordance with the Care Act
2014 and Department of Health guidance, you will need to have a means
tested financial assessment to determine what you need to contribute
towards the cost of your care and /or support.
The amount you are assessed as being able to afford to contribute, will differ
depending where the care and support is taken. If this setting changes for
example, you initially have care and support met whilst at home but need to
have a period of respite care in a care home setting, a new assessment
would be required and the amount you would be asked to contribute would
change. You will be notified in writing each time a financial assessment is
completed, giving you a breakdown the how we have assessed your
contribution.
Please note that any assessed contribution is to be paid for the income of the
person receiving care and support. If the care is provided in a long term
residential or nursing care home setting and there is an agreed above
banding supplement or top up, this is not to be paid out the persons income
but is usually paid by a third party.
A member of the Care Contribution Assessment team will contact you shortly
to complete a financial assessment with you. They will need details of any
capital you may have, along with details of your income, housing costs and
any exceptional expenditure relating to your illness or disability. The
contribution you are assessed as being able to afford will commence from the
date you start to receive care and/or support.
Adult Services and
Health
If when the assessment is completed, it is identified that you are entitled to
further benefits the officer will inform you of how to make a claim.
If your financial situation changes at all you must let us know so we can
ensure your contribution is correct. Any change to your contribution will take
effect from the date when your circumstances changed and over payment or
under payment will be backdated.
CCN- Care Act v3 Aug 2015
It is important to note, that this includes where you have been awarded any
additional income, for example a state benefit, the assessment will take affect
from the date the income or benefit was awarded and you will be asked to
pay any increased contribution from the date of the award.
If you have capital over £23,250.00, or you do not wish to have a financial
assessment or disclose details of your capital and income you will be
expected to pay for your care in full.
MAKING A PROVISIONAL CONTRIBUTION WHILE WE ARE
COMPLETING THE ASSESSMENT
Whilst we are gathering information to be able to accurately calculate how
much you are assessed as being able to pay, you will be charged a basic
rate called a 'provisional contribution'. This amount will depend on where the
care and support is being provided, for example in a care home or other
setting.
If your care and/or support is being taken in a care home setting, you will be
asked to pay the provisional amount of £126.30 per week if you are aged
over 62 years and £80.45 per week if you are aged under 62 years old.
If your care and support is being provided in a non-care home setting, for
example at home, you will be asked to pay the provisional amount of £21.80
per week.
Once we have completed the full financial assessment, if your assessed
charge is lower than this relevant provisional rate, you will be refunded the
difference. Should your assessed charge be more than the basic rate the
higher charge will be applied from the date your care and support
commenced.
Yours sincerely
Team Manager
Privacy Notice: Worcestershire County Council is under a duty to protect the public
funds it administers, and to this end may use the information you have provided for the
prevention and detection of fraud. It may also share this information with other bodies
responsible for auditing or administering public funds for these purposes.
Part B
CCN- Care Act v3 Aug 2015
DECLARATION TO BE COMPLETED WITH SERVICE USER AT VISIT
Service User Full Name:
Date of Birth:
/
/
Date of Birth:
/
/
National Insurance No:
Partner's Full Name:
National Insurance No:
Address:
I confirm I have read Part A and understand that if I receive any care and support now or in the future, which is a
chargeable service that I may have to contribute towards this. I agree that Worcestershire County Council can contact
Department for Works and Pensions to verify the amount of benefits I receive and share any personal and financial
information I have provided to The Pension Service or Worcestershire County Council, for the purpose of assessing
either my entitlement(s) to benefits or financial assessments in relation to my care.
I consent to you sharing information with : (insert name)______________________________________________
Who is a family member / friend / carer (circle as appropriate) and my nominated *financial representative
(If nominating a financial representative please ensure that you sign where indicated below)
I understand that I may withdraw my consent to the disclosure of such information and change my financial
representative at any time by writing to The Care Contribution Manager, Worcestershire County Council, County Hall,
Spetchley Road, Worcester, WR5 2NP.
I confirm I have received the Financial Assessment Information Pack
I understand that any services arranged by the Council are chargeable and the amount I will pay will
depend on my individual finances circumstances and type of service I receive.
I have *capital under £23,250.00 and I wish to have a financial assessment completed and my benefit
entitlement reviewed.
(You will be contacted by The Care Contribution Team shortly)
I have *capital over £23,250.00
I do not wish to disclose any financial information and agree to pay the full cost of my care.
Due to my physical disability (please state) __________________________ I am unable to sign this form
but agree to this declaration. (If you are unable to sign a **Witness is required to sign below, where indicated, to
verify this statement, this must be an independent 3rd party i.e. neighbour/healthcare professional).
Service User's Signature:
Date:
Partner's Signature:
Date:
Appointee/Power of Attorney Signature:
Date:
**Witness' Print Name:
**Witness' Signature:
**Witness' Position:
*Refer to Glossary in the Information Pack
Date:
Office Use Only - Please scan and upload
Name of Worker:
Team Name:
Job Title:
Signature:
Date:
CCN- Care Act v3 Aug 2015
Part C
DECLARATION TO BE COMPLETED WITH SERVICE USER AT VISIT – CUSTOMER COPY
Service User Full Name:
Date of Birth:
/
/
Date of Birth:
/
/
National Insurance No:
Partner's Full Name:
National Insurance No:
Address:
I confirm I have read Part A and understand that if I receive any care and support now or in the future, which is a
chargeable service that I may have to contribute towards this. I agree that Worcestershire County Council can contact
Department for Works and Pensions to verify the amount of benefits I receive and share any personal and financial
information I have provided to The Pension Service or Worcestershire County Council, for the purpose of assessing
either my entitlement(s) to benefits or financial assessments in relation to my care.
I consent to you sharing information with : (insert name)______________________________________________
Who is a family member / friend / carer (circle as appropriate) and my nominated *financial representative.
(If nominating a financial representative please ensure that you sign where indicated below)
I understand that I may withdraw my consent to the disclosure of such information and change my financial
representative at any time by writing to The Care Contribution Manager, Worcestershire County Council, County Hall,
Spetchley Road, Worcester, WR5 2NP.
I confirm I have received the Financial Assessment Information Pack
I understand that any services arranged by the Council are chargeable and the amount I will pay will
depend on my individual finances circumstances and type of service I receive.
I have *capital under £23,250.00 and I wish to have a financial assessment completed and my benefit
entitlement reviewed.
(You will be contacted by The Care Contribution Team shortly)
I have *capital over £23,250.00
I do not wish to disclose any financial information and agree to pay the full cost of
my care.
Due to my physical disability (please state) __________________________ I am unable to sign this form
but agree to this declaration. (If you are unable to sign a **Witness is required to sign below, where
indicated, to verify this statement, this must be an independent 3rd party i.e. neighbour/healthcare
professional).
Service User's Signature:
Date:
Partner's Signature:
Date:
Appointee/Power of Attorney Signature:
Date:
**Witness' Name:
**Witness' Signature:
Date:
**Witness' Position:
*Refer to Glossary in the Information Pack
Office Use Only - Please leave this copy with the Service User
Name of Worker:
Job Title:
Team Name:
Signature:
Date: