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Information we need from you

It is vital you give us as much information about treatment and prognosis as possible. If information is missing, we will contact you once. If it is not then supplied, we will complete the support we can from the information we hold and close the referral. This may mean the person misses out on benefits they are entitled to.

Please also:

Inform us whether the person is aware of their SR1 status
If a person is SR1 eligible, please upload a copy
If you have selected that the person is SR1 eligible but the SR1 has not been issued yet, please use the additional information section to explain the situation, for example the reason for delay and timescale for issues if known
If you have electronically submitted the form to the DWP, please still upload a copy.

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Provided by Macmillan Money and More South West (North) Citizens Advice Partnership

This form is for people with a current cancer diagnosis who would like help with benefits or money concerns. You can fill it for yourself or someone else can do it for you, for example, a friend, family member, a carer or medical professional.

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Guidance text: Please note, the maximum file size that can be uploaded is 20 MB.

Most file types are accepted. Only the initial page of TIFF files can be viewed so please don't add multi-page TIFF files.

Upload times may vary depending on your internet speed. Please do not refresh the page whilst uploading your files, and wait until complete.

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Please use this section to give a brief summary of the reason for your referral, including any specific concerns or advice the person would like. Please also use this section to highlight any relevant information, including:

Details of any benefits the person is already in receipt of
Whether the person is currently in hospital
The reason for any delay in the SR1 being issued.

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The questions within this section are related to the person acting in capacity as the representative.

The person with cancer may want to give consent for someone else, e.g. a family member, to speak to us. We need consent from the person with cancer for us to to speak to anyone else.

Please note: a person who has power of attorney or other legal authority from the person with cancer can act as though they are the person with cancer when giving us consent.

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Consent for us to act

Does the person give consent for Citizens Advice to:

Speak and act with external agencies on their behalf about welfare benefits and other matters that may provide them with a financial or material advantage, such as a Blue Badge?
Share their contact details, National Insurance number, health information and any other necessary information with benefits agencies, where required?

This includes permission for Citizens Advice to obtain essential medical information from health staff when it’s needed as evidence to support benefit and other claims.

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Citizens Advice speaking with other agencies and acting on your behalf

We will need to speak directly to you if you want us to take any action on your behalf. Only in exceptional circumstances can a medical professional get consent from you for us to act on your behalf.

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If you would like to receive an acknowledgement email after submitting this referral, please provide your email address

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Privacy statement

We need to record information about you and the people mentioned in this form to help with your referral. If you would like to know more about how we use your data, please visit www.citizensadvice.org.uk/myinformation in respect of information held on the national case management system and www.bristolcab.org.uk/privacy-policy/ for information held on this portal.

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