Authorising a person or organisation to act on your behalf - COVID-19 Vaccine Claims Scheme form (MO064)

Use this form to authorise a person or organisation to make a claim under the COVID-19 Vaccine Claims Scheme on your behalf.

Download and complete the Authorising a person or organisation to act on your behalf - COVID-19 Vaccine Claims Scheme.

If you’re unable to complete this form, you can authorise someone to do it on your behalf. They also need to submit:

Before they complete this form, check if you’re eligible under the scheme and what proof you need. Find out more about the COVID-19 Vaccine Claims Scheme.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 9 April 2022