Version Version ScreenVersionNumber NHS Help with Health Costs

LIS Form Ordering

Applications can only be made if you are a resident in England.

Please enter address details below:




* Mandatory Fields

Your Information

The NHS Business Services Authority will share the information that you give with our supplier who then post the forms to you. We will retain your address information for no more than a year to monitor trends in how customers order the application form and the number of completed forms we receive. Further details, including our exemption checking process and your information rights are available at