Personal Health Budgets – Direct Payments Agreement The agreement This is an agreement between you/the patient and NHS Norfolk Primary Care Trust (PCT) and is a legally binding contract. The agreement details the PCT’s commitment to providing the money to you/the patient to fulfil the cost of your health needs and details the processes for carrying this out. Representative You may identify a person (as agreed with the PCT) who will receive and manage the money on your behalf. This person must take full responsibility for managing the money and when they sign the agreement, they are agreeing to do this. This person is called a 3 rd Party. Representative You may identify a person (as agreed with the PCT) who will receive and manage the money on your behalf. This person must take full responsibility for managing the money and when they sign the agreement, they are agreeing to do this. This person is called a 3 rd Party. Requirements of the agreement If this agreement is changed or ended (either by you or your representative or the PCT) this must be agreed between you or your representative and the PCT, you will receive or give at least 4 weeks notice. However, where theft, fraud or another offence has taken place, or your representative refuses or is unable to manage the PHB, the PCT will end this agreement with immediate effect. Payments All money will be paid to you or your representative by the PCT. You or your representative is required to keep a separate bank account, to which this money will be paid. This bank account must only be used for receiving, spending and managing your PHB (and where applicable a social care personal budget and independent living fund). Money cannot be transferred into any other bank account for any other purpose except as defined in your Personal Health Budget Support Plan (Support Plan). Any costs of repairs, insurance or replacement for any equipment you purchase will need to be discussed and agreed as part of your Support Plan. The money can be paid to you monthly, quarterly or as a one-off lump sum. You will be informed of this in your Approval letter. You will need to complete the attached Bank Account details in order for us to pay you any money. You must sign this agreement and, if another person is looking after your money, they too must sign this agreement also. Please note – organisations do not as they have already signed another document. Payments All money will be paid to you or your representative by the PCT. You or your representative is required to keep a separate bank account, to which this money will be paid. This bank account must only be used for receiving, spending and managing your PHB (and where applicable a social care personal budget and independent living fund). Money cannot be transferred into any other bank account for any other purpose except as defined in your Personal Health Budget Support Plan (Support Plan). Any costs of repairs, insurance or replacement for any equipment you purchase will need to be discussed and agreed as part of your Support Plan. The money can be paid to you monthly, quarterly or as a one-off lump sum. You will be informed of this in your Approval letter. You will need to complete the attached Bank Account details in order for us to pay you any money. You must sign this agreement and, if another person is looking after your money, they too must sign this agreement also. Please note – organisations do not as they have already signed another document.

1.By signing the agreement you or your representative are agreeing that your current health outcomes, as agreed in your plan, can be met by your Support Plan. 2.Your PHB must not be spent on anything that is not detailed in your Support Plan unless you have already agreed it with the PCT. 3.You must keep all receipts and other documents (e.g. bank statements) associated with your Support Plan, as the PCT will need to see these. 4.These records must be kept for at least six years. 5.You must ensure that your chosen care provider looks after you according to recognised standards and regulations. 6.Your Support Plan will be reviewed on a quarterly basis from the date of your first payment. Further reviews may be requested at any time. 7.You must notify your key worker and the PCT if there are any significant changes (e.g. to your health, if you have to go to hospital, or are no longer able to manage your PHB yourself, or you move to a different address). 1.By signing the agreement you or your representative are agreeing that your current health outcomes, as agreed in your plan, can be met by your Support Plan. 2.Your PHB must not be spent on anything that is not detailed in your Support Plan unless you have already agreed it with the PCT. 3.You must keep all receipts and other documents (e.g. bank statements) associated with your Support Plan, as the PCT will need to see these. 4.These records must be kept for at least six years. 5.You must ensure that your chosen care provider looks after you according to recognised standards and regulations. 6.Your Support Plan will be reviewed on a quarterly basis from the date of your first payment. Further reviews may be requested at any time. 7.You must notify your key worker and the PCT if there are any significant changes (e.g. to your health, if you have to go to hospital, or are no longer able to manage your PHB yourself, or you move to a different address). 14The PCT will not allow an immediate family member, living in the same household to provide the care under this agreement unless clearly agreed with the PCT as part of your Support Plan. 15The PCT can recover any payments or over payments from you, which have not been used, as described in your Support Plan. 16If you are not happy with any decisions made after the agreement has been signed you may contact the PCT detailing the disagreement via the contact details below. 17You have the right to complain and may do this via the PCT complaints process. 18The NHS Norfolk Patient Advice and Liaison Service can be contacted on for this. 19Please send all other queries to either or to 14The PCT will not allow an immediate family member, living in the same household to provide the care under this agreement unless clearly agreed with the PCT as part of your Support Plan. 15The PCT can recover any payments or over payments from you, which have not been used, as described in your Support Plan. 16If you are not happy with any decisions made after the agreement has been signed you may contact the PCT detailing the disagreement via the contact details below. 17You have the right to complain and may do this via the PCT complaints process. 18The NHS Norfolk Patient Advice and Liaison Service can be contacted on for this. 19Please send all other queries to either or to 8If payment is not required for 28 days or more, e.g. you are admitted to hospital, the PCT may suspend or discontinue payments. You are required to notify the PCT should this happen. 9If you or your representative does not spend the PHB, as detailed in your Support Plan, the PCT can demand repayment, withdraw the PHB and/or arrange for someone else to take over management of your PHB. 10Where family/friends provide your care it is your decision whether you ask them to carry out a CRB check, but you must ensure that CRB checks are undertaken on anyone else that is providing your care. 11If you directly employ your carers, you must have employers’ liability insurance and use an accredited payroll service, these and all other associated costs must be detailed in your Support Plan. 12You are reminded that in the event of your death the PHB would not form part of your estate. 13Your key worker will carry out the reviews associated with your Support Plan. They will also act as the link between you and the PCT. 8If payment is not required for 28 days or more, e.g. you are admitted to hospital, the PCT may suspend or discontinue payments. You are required to notify the PCT should this happen. 9If you or your representative does not spend the PHB, as detailed in your Support Plan, the PCT can demand repayment, withdraw the PHB and/or arrange for someone else to take over management of your PHB. 10Where family/friends provide your care it is your decision whether you ask them to carry out a CRB check, but you must ensure that CRB checks are undertaken on anyone else that is providing your care. 11If you directly employ your carers, you must have employers’ liability insurance and use an accredited payroll service, these and all other associated costs must be detailed in your Support Plan. 12You are reminded that in the event of your death the PHB would not form part of your estate. 13Your key worker will carry out the reviews associated with your Support Plan. They will also act as the link between you and the PCT. Your key worker is the person who signed off your Support Plan. The PCT may ask another organisation to carry out the quarterly reviews on their behalf. Any information provided will be sufficient for this review and will remain confidential.

Bank Account Details - You must complete this form Please note – the 3 rd Party can be someone who consents / hold the money if the person the budget is for lacks capacity Your NameJoint Account Holder / 3 rd Party Your AddressJoint Account Holder / 3 rd Party Address The Name of the Bank receiving the Personal Health Budget: Sort-Code: Bank Account Number: You must sign the document over-leaf now Any Joint Account Holders must also sign this document. Someone else looking after your Budget must also sign this document unless it is an organisation

You must sign this page Please note – if the person the budget is for lacks capacity to sign, the 3 rd Party must sign this form By signing this document you agree to the Terms and Conditions on Pages 1 and 2 of this document. You confirm the Bank Account information provided is correct. Your signature Joint Account Holder / 3 rd Party signature (not required if it is an organisation) NHS Norfolk’s signature Date signed NHS Norfolk (the PCT) is registered at Lakeside 400, Old Chapel Way, Broadland Business Park, Thorpe St Andrew, Norwich, Norfolk, NR7 0WG