A form healthcare professionals fill in if DWP asks for information in connection with Employment and Support Allowance or Universal Credit.
Ref: ESA113 (interactive)
PDF, 113KB, 2 pages
We use form ESA113 to ask healthcare professionals for information in connection with Employment and Support Allowance and Universal Credit claims.
We may ask you to complete this form if we think that your patient may have a severe health condition or disability but do not have enough information to be sure.
Download the template onto your practice server.
When you receive a request for information on form ESA113:
Type in the details of the claimant (name, address, National Insurance number and date of birth).
Fill in the rest of the form.
Print the form, sign it and complete the practice stamp section.
Send the completed form to Centre for Health and Disability Assessments in the return window envelope that came with the request. Please make sure that the return address is visible.
There is more information about completing medical reports in DWP factual medical reports: guidance for healthcare professionals
Employment and Support Allowance
Don’t include personal or financial information like your National Insurance number or credit card details.
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