S.I. No. 87/2024 - Mother and Baby Institutions Payment Scheme Act 2023 (Reviews) Regulations 2024

1. Your Details

*Your name

*Your address

*Application Reference Number

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-

*Your Application Reference Number can be found on your Notice of Determination or the most recent correspondence from the Payment Scheme Office.

2. Reasons for Review

This section of the form should be used to explain your reasons for seeking a review under

Section 27

of the

Mother and Baby Institutions Payment Scheme Act 2023

. You must select one or more reasons from the following list by ticking the relevant box.

I would like the following determinations to be reviewed by the Chief Deciding Officer

□Review a determination that I am not a relevant person;

□Review a determination that I am not entitled to a general payment or a work- related payment;

□Review a determination that I am entitled to a general payment or a work- related payment of a particular amount;

□Review a determination that I am not eligible for the provision without charge of health services;

□Review a determination (including a determination under section 25 (2)) that I am not entitled to a health support payment.

The following section should be used to describe your reasons for the request to review your determination. If you need additional space please use page 4 of this form or add additional pages as required.

3. Supporting Documentation

You are not required to submit supporting documentation, however, where you do have documentation which would support your review we would ask that you attach a copy of these records. Please list the records you have attached in the space provided below (if you need to list more documents please use the space on page 4 of this form).

1

2

3

4

4. Confirmation of Request for Review of Determination

I hereby request a review of the Chief Deciding Officer’s determination(s)

of ___/____/ 20___

My grounds for review are set out in Section 2 and the information provided by me is true and accurate.

Signed: __________________________

Print name: __________________________

Date: ______/______/ 20_____

Where the applicant has a Co-Decision Making Agreement in place which covers arrangements under this Payment Scheme

Signed: _________________________ (Co-Decision Maker)

Print name: _____________________________

Date: ____/____/20___

5. Checklist

[ ] Notice of Request for Review of Determination is being submitted within 60 days of the date on the Notice of Determination issued by the Chief Deciding Officer.

[ ] All relevant sections of the Review Request form are fully completed.

[ ] Review Request form is signed and dated at Part 4.

[ ] Grounds for request for review of determination are fully stated and all facts for consideration are stated.

[ ] Supporting documentation are attached with this form (where available).

[ ] All supplementary documentation (if available and attached) are listed at Part 3 of this form.

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of

8

th March,

2024.

I, RODERIC O’GORMAN, Minister for Children, Equality, Disability, Integration and Youth, in exercise of the powers conferred on me by

section 44

(2)(b) of the

Mother and Baby Institutions Payment Scheme Act 2023

(No.20 of 2023), hereby make the following Regulations

Citation and commencement