Centro Comunitário Paroquial de Famões

IPSS — Odivelas, Portugal

Application Form — Seniors

Fill in the form with the senior's details. Upon submission you will receive an email with the application number and a link to follow the status.

Service requested

Service

1. User identification

Full name

Preferred name

Date of birth

Gender

Address

Postal code

Locality

Document type

ID Document number

Valid until

Tax ID (NIF)

Social Security ID (NISS)

Health Service ID (SNS)

ℹ️ Provide at least one: Tax ID, Social Security, ID card, Passport or Residence card.

Phone

Mobile

Email (to receive confirmation)

Health centre

Assistant doctor

Person responsible for the application (if applicable)

Fill in if the application is made by a family member/representative.

Name

Relationship

Mobile

2. Household members

Name	Relationship	Age	Occupation	Monthly income (€)

3. Monthly expenses

Housing (rent/bank) (€)

Type

Health (chronic illness) (€)

Transport (pass) (€)

4. Emergency contacts

⭐ Primary contact

Name

Relationship

Mobile

Other contact

Name

Relationship

Mobile

5. Priority criteria

Tick those that apply (auto-declared — will be verified):

a) Need for the service to remain in family context and/or own home

b) Documented economic hardship

c) Social isolation risk

e) Family member already attending

f) Referred by Social Security

j) [Day Centre] Risk of accelerated ageing

k) [Day Centre] Full or partial autonomy

l) [Home Support] Residence in Odivelas / Pontinha-Famões

m) [Home Support] No family / unable to provide care

n) [Home Support] Needs care 5 or 7 days

6. Reason for application

Briefly describe the reason for the application (optional)

Documents

Documents to provide:

Documento de Identificação (CC/Passaporte/BI)
Nº Identificação da Segurança Social (NISS)
CC do responsável
Nº de Identificação Fiscal (NIF)
Nº de Utente (SNS)
ADSE
IRS modelo 3 e nota de liquidação
Comprovativo de renda de casa ou prestação ao banco (habitação)
Comprovativo de aquisição de título de transportes públicos
Declaração da farmácia (custo médio mensal medicação crónica c/ discriminação)
Declaração médica de demência (psiquiatria/neurologia)
Complemento por dependência — Grau I ou II
Relatório médico com informação clínica e medicação diária actualizada
Cópia do último IRS / nota de liquidação do agregado
Cópia de despesas de familiares em ERPI
Cópia dos encargos com saúde/passe do agregado

Upload your documents (you can select several). On a mobile phone, the button lets you take a photo directly.

I confirm I do not wish to upload documents now. I will do it in person.

7. Consent and data protection

I consent to the processing of the personal data submitted for the purpose of evaluating this application. The data may be transmitted to Social Security and/or Odivelas Municipality for co-payment purposes. I acknowledge the institution's privacy policy.

I have read and accept *

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