Medical Assist application form

If you need to apply for Medical Assist or renew your existing Medical Assist allowance, please complete the application below.

Before starting, please make sure you have a copy of your Continence Aids Payment Scheme (CAPS) statement of payment handy (PDF, JPEF or PNG format), as you will need to attach this before you can submit your application.

Please note: If you don’t qualify for Medical Assist but have special water needs such as using a dialysis machine, life-support equipment or requiring a constant water supply for medical reasons, you can still apply using this form.

All fields are required unless marked as optional

CAPS recipient details

Select your application type Submit new application Renew existing application

First name *

Last name *

Property details for this application

Account number (optional)

Street address *

Suburb *

Postcode *

Does the CAPS recipient currently live at this property * Yes No

What is the relation of the applicant living at this residence?

Relation to applicant *

Select a status for the applicant * Property owner Family member Tenant Other

Please specify *

Contact details

Primary contact name *

Primary contact mobile number *

Primary contact email address *

Secondary contact name *

Secondary contact mobile number *

Other contact phone number *

Statement of payment

To qualify for the Medical Assist allowance you need to provide your CAPS statement of payment. We accept scans or photos of the original copy.

Attach your statement of payment *

Files should be in PDF, JPEG or PNG.

Declaration

By submitting this Medical Assist application I/We declare that:

a. I/We am the Applicant;
b. All information provided in this application is, to the best of my knowledge, true and accurate and not misleading;
c. I/We will immediately notify Water Corporation of any changes to the contact details specified.
d. I/We consent to Water Corporation collecting, storing and using the personal information given as part of my/our contact details in accordance with Water Corporation’s privacy policy for the purposes of providing a water service to me/us, and in particular for the purposes of contacting me/us by SMS/Email in the event Water Corporation plans to complete work on assets that have an impact on my/our water supply.
e. I/We acknowledge that Water Corporation will notify of planned interruptions to the supply via SMS/Email.

I agree to the above declaration *