Form

ESA113 (interactive): for use by healthcare professionals

A form healthcare professionals fill in if DWP asks for information in connection with Employment and Support Allowance or Universal Credit.

• From: Department for Work and Pensions
• Published: 10 March 2011
• Last updated: 13 March 2023 — See all updates

Documents

ESA113 About your patient

Ref: ESA113 (interactive)

PDF, 192 KB, 6 pages

This file may not be suitable for users of assistive technology.

Request an accessible format.

If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email [email protected]. Please tell us what format you need. It will help us if you say what assistive technology you use.

Details

We use form ESA113 to ask healthcare professionals for information in connection with Employment and Support Allowance or 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.

How to use this form ESA113

Download the template onto your practice server.

When you receive a request for information on form ESA113:

1. Type in the details of the claimant (name, address, National Insurance number and date of birth).

2. Fill in the rest of the form.

3. Print the form, sign it and complete the practice stamp section.

4. 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

Information for claimants

• Employment and Support Allowance
• Universal Credit

Published 10 March 2011
Last updated 13 March 2023 + show all updates

1. 13 March 2023

   Updated form ESA 113 About your patient.

2. 2 March 2023

   Updated form ESA 113 About your patient.

3. 22 February 2023

   Updated to explain that form ESA113 can be completed by healthcare professionals if DWP asks for information in connection with Universal Credit.

4. 19 November 2021

   Published new version of the form that can be filled in online.

5. 22 July 2016

   Updated the page to show that the form applies to Universal Credit as well as ESA cases.

6. 10 March 2011

   First published.