Fillable Printable Medical Card and GP Visit Card Application Form - Dublin
Fillable Printable Medical Card and GP Visit Card Application Form - Dublin
Medical Card and GP Visit Card Application Form - Dublin
Who should use this form?
Anyone applying for either a Medical Card or a GP Visit Card – you will be assessed for both.
How do I apply for a Medical Card or a GP Visit Card?
Step 1. Complete this form. Read this page and the next page for help.
Step 2. Include all the documents we ask for in Part 3 and Part 4. Please send photocopies only.
Step 3. Read and sign the declaraon in Part 5.
Step 4. Ask your doctor of choice to complete Part 6A and, if appropriate, ask your spouse’s or partner’s doctor
to complete Part 7A.
Step 5. Read and ck the checklist on page 12.
Step 6. Send the completed applicaon form and copies of all the documents we ask for, to:
Client Registraon Unit, PO Box 11745, Dublin 11.
What can I do to avoid delaying the process?
If you send us a fully completed form and all the documents we ask for, we will deal with your applicaon quickly
and will let you know within 15 working days if you are entled to a card. So to avoid delay, ensure to do the
following:
• take care to ll in all your details correctly,
• include copies of all the documents we ask for in Part 3 and Part 4, and
• make sure the documents you send us are up to date.
If you do not include all the informaon we ask for, we will have to write to you for the missing informaon.
Need help?
Read this page and the next page for help. If you need further help compleng this form, phone
Callsave 1890 252 919 or visit your Local Health Oce.
Medical Card and GP Visit Card
Applicaon Form
MC1
Medical Card and GP Visit Card Form MC1 1
MC1 June 2014
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2 Medical Card and GP Visit Card Form MC1
Help and informaon
Who can apply for a Medical Card or a GP Visit Card?
Anyone who is ‘ordinarily resident’ in the Republic of Ireland
can apply - families, single people, even those working full
or part me. ‘Ordinarily resident’ means that you are living
here and intend to live here for at least one year.
I am aged between 16 and 25. How do I apply?
1. If you have a weekly income of less than €164 and
you are either living with your parent(s) or living away
from their home aending school or college, and your
parent(s) has a Medical Card or a GP Visit Card, you
must complete Parts 1A, 1C, 1D, 5, and 6 of this form.
Your doctor of choice must complete Part 6A.
2. If you have a weekly income of less than €164 a week
and you are either living with your parent(s) or living
away from their home aending school or college, and
your parent(s) don’t have a Medical Card or a GP Visit
Card, your parent(s) must complete all parts of this
form.
3. If you have a weekly income of €164 or more, you must
complete all parts of this form.
4. If you live away from your parental home for any reason
other than aending school or college, you must
complete all parts of this form.
How do I qualify for a Medical Card or a GP Visit Card?
Firstly, we will look at your household income aer tax,
PRSI and the Universal Social Charge (USC) have been
deducted. We also take rent, mortgage, childcare and
travel to work costs into account. If the resulng gure is
less than the income qualifying limits, you and your family
dependants will be issued with a card.
For informaon on the current income qualifying limits
that apply to your family size, Callsave 1890 252 919 or
see our website www.medicalcard.ie.
Will my savings and investments be taken into
account when assessing my income for Medical Card or
GP Visit Card eligibility?
We will not take into account savings or investments of
amounts:
• up to €36,000 for a single person, or
• up to €72,000 for a couple.
Also, we will not take into account any amount received
from certain state sponsored compensaon or redress
schemes or any interest earned on the investment of these
funds.
For informaon on the specic compensaon or redress
schemes covered by this secon, please see
www.medicalcard.ie or phone Callsave 1890 252 919.
What if my household income is over the qualifying
limits?
If this is the case, you and your family dependants may
be granted a Medical Card or a GP Visit Card if you have
dicult personal circumstances that cause you nancial
pressure - for example a family member with a chronic
illness. You need to send evidence with your completed
applicaon form in support of these circumstances,
for example, a medical report and or medical expense
receipts.
If I get a Medical Card or a GP Visit Card, does it cover my
family too?
If your family income falls within the qualifying income
limits, the card will cover you, your spouse or partner, and
your children under 16 years of age.
If your children are aged 16 to 25 and are receiving weekly
income less than €164, and living with you or living away from
you to aend school or college, they will also get a card. They
must ll out their own applicaon form and send it to us to
receive a card.
How do I qualify for a Medical Card under European
Union (EU) Regulaons?
You will qualify for a Medical Card under EU Regulaons if
you meet all of the following requirements:
• you are ordinarily resident in the Republic of Ireland,
• you are insured under the social security legislaon
of another EU/EEA member state or Switzerland, that
means receiving a social security pension from that
state or working and paying social insurance in that
state, and
• you are not subject to Irish social security legislaon
- you are subject to Irish social security legislaon if
you are receiving a contributory Irish social welfare
payment or if you are subject to PRSI in the Irish state.
If you meet the above requirements, you can claim your
entlement to a Medical Card by sending us:
• a completed applicaon form, and
• the relevant E or S form issued by the EU/EEA
member state (or Switzerland) you are insured with.
UK insured persons applying under EU Regulaons should
send us a leer of conrmaon from the UK Pensions
Board or a recent payslip (if employed in UK) in place of
the E or S form.
MC1 June 2014
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Medical Card and GP Visit Card Form MC1 3
FOR OFFICIAL USE ONLY
Application No.:
Date Received:
1A ̶ Your details
First name(s): Surname:
Date of birth:
Birth surname:
(If dierent)
PPS number: Gender: Male Female
Address:
Mobile phone:
(If you enter your mobile phone we may text you in connecon with
your applicaon)
Dayme phone:
Country of birth: Email address:
How long have you lived in Ireland?
Are you ordinarily resident in Ireland?
(See top of page 2 for denion of ‘ordinarily resident’.) Yes No
Do you live alone? Yes No
If ‘No’, who do you live with?
Are you:
Single Married Cohabing In a Civil Partnership Widowed Separated Divorced
Do you have, or have you ever had, a Medical Card or a GP Visit Card? Yes No
If ‘Yes’, please ck the kind of card and write in the number:
Medical Card GP Visit Card Card Number
Part 1 ̶ Personal details
1B ̶ Details for your spouse or partner (If you don’t have a spouse or partner, please go to next page)
First name(s): Surname:
Date of birth:
Birth surname:
(If dierent)
PPS number: Gender: Male Female
Is your spouse or partner ordinarily resident in Ireland? Yes No
Does your spouse or partner have, or has he or she ever had, a Medical Card or a GP Visit Card? Yes No
If ‘Yes’, please ck the kind of card and write in the number:
Medical Card GP Visit Card Card Number
D D M M Y Y Y Y
D D M M Y Y Y Y
For Parts 1, 2, 3, 4, 6 and 7 that apply
to you, please complete in CAPITAL
LETTERS and place a ck (
) where
appropriate in the single boxes
provided.
MC1 June 2014
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
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Y
Y
Y
Y
Y
Y
Y
Y
Y
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Y
Y
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Y
Y
Y
Y
Y
Y
Y
4 Medical Card and GP Visit Card Form MC1
1C – If you are a person aged between 16 and 25 and if you have a weekly income of less
than €164, please complete this secon
Does your parent(s) have a Medical Card or a GP Visit Card? Yes No
If ‘Yes’ and if you are living with your parent(s) or living away from parental home for purposes of aending
school or college, you only need to:
•
complete Parts 1A, 1C, 1D, 5 and 6 of this form,
•
ask your doctor of choice to complete Part 6A, and
•
ck the kind of card your parent(s) has and write in the number below.
Medical Card GP Visit Card Card Number
If ‘No’ and if you are living with your parent(s) or living away from parental home for purposes of aending
school or college, your parents must complete all parts of this form, lisng you as a dependant aged 16-25.
1D - Aending school or third level college?
Are you in school or third level educaon? Yes No
If ‘Yes’, what is the name of your school or college?
When will you nish your course?
Please ask your school or college to stamp this form.
School or college stamp:
Part 2 ̶ Your dependants
Your dependants aged under 16
First name Surname Date of birth PPS number Relaonship
to you
D D M M Y Y Y Y
MC1 June 2014
Medical Card and GP Visit Card Form MC1 5
Part 2 ̶ Your dependants ̶ connued
Your dependants aged between 16 and 25 in school or college or receiving an income of
less than €164 per week
Part 3 ̶ Details of income
(Please give details of all income that you and your spouse or partner receive each week)
First name Surname Date of birth PPS number Relaonship Receiving a
to you 3rd level
educaon
grant?
Yes No
Yes No
Yes No
Yes No
Yes No
D
D
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Source Amount
Frequency of
payment
(for example,
weekly, fortnightly,
monthly or yearly)
Type of
payment
Documents to send to us
(Photocopies only please)
Recent An Post receipt slip or
recent bank statement (if
payment is paid direct to bank
account). If in receipt of Illness
Benet or Maternity Benet,
a leer from your employer
conrming your current wage, if
any, in addion to Social Welfare
payment
Social Welfare E
payments
Most recent payslip
Wages and or pension E
(1) Latest Noce of Assessment
from Revenue Commissioners
or (2) Latest Noce of Self-
Assessment and a copy of your
latest Tax Return as acknowledged
by Revenue Commissioners.
Income from E
self employment
Relevant documentaon from the
other EEA State or Switzerland,
i.e. relevant E or S form, e.g. E121
or S1. If in receipt of UK social
welfare payment, leer from Dept
for Work and Pension UK detailing
payment amount and frequency.
Social security payments E
from another EU state
Please put the name
of the EU state here:
Relevant documentary evidence
Any other income E
(for example, maintenance
payments, social security
payments from non-EU state)
A. Your income details
MC1 June 2014
Source Amount
Frequency of
payment
(for example,
weekly, fortnightly,
monthly or yearly)
Type of
payment
Documents to send to us
(Photocopies only please)
Recent An Post receipt slip or
recent bank statement (if payment
is paid direct to bank account).
If in receipt of Illness Benet or
Maternity Benet, a leer from
your employer conrming your
current wage, if any, in addion to
Social Welfare payment
Social Welfare E
payments
Most recent payslip
Wages and or pension E
(1) Latest Noce of Assessment
from Revenue Commissioners
or (2) Latest Noce of Self-
Assessment and a copy of
your latest Tax Return as
acknowledged by Revenue
Commissioners.
Income from E
self employment
Relevant documentaon from the
other EEA State or Switzerland,
i.e. relevant E or S form, e.g. E121
or S1. If in receipt of UK social
welfare payment, leer from
Dept for Work and Pension UK
detailing payment amount and
frequency.
Social security payments E
from another EU state
Please put the name
of the EU state here:
Relevant documentary evidence
Any other income E
(for example, maintenance
payments, social security
payments from non-EU state)
6 Medical Card and GP Visit Card Form MC1
Part 3 ̶ Details of income ̶ connued
B. Your spouse’s or partner’s income details
(If you do not have a spouse or partner, please go to secon C on this page)
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
MC1 June 2014
C. Back to employment or educaon scheme (for example, Community Employment Scheme)
(If you are not working on or aending such schemes, please go to secon D on next page)
Please send us:
•
a leer(s) from the scheme supervisor(s) showing the start date and expected nish date for you
and or your spouse, and
•
a copy of the most recent payslip(s).
Scheme type Start date Expected nish date
You
Scheme type Start date Expected nish date
Spouse or
partner
Part 3 ̶ Details of income ̶ connued
D. Savings and investments
If you don’t have enough room to complete this secon, please write addional details on a separate sheet
of paper and send it in with this form.
If you don’t have enough room to complete this secon, please write addional details on a separate sheet
of paper and send it in with this form.
Amount(s) invested
or held in savings E
Address Details of land or property
(for example, 3 bed semi, shop
unit, farmland or other)
Yearly income received
(for example, from rental,
from lease or from other)
Yearly costs €
Type of savings or investmentsName and address of nancial instuon
where invested or deposited
Do you or your spouse or partner have investments in stocks, shares or savings
with banks or building sociees or other nancial instuons? Yes No
If ‘No’, go to Part E on this page.
If ‘Yes’, please complete the details below and remember to aach photocopies of the documents you need
to send us as evidence of your income from these sources, for example, statement(s) from nancial
instuon(s) showing the current balance on account(s).
E. Property addional to the family home
Do you or your spouse or partner own any property or land other than the
house you live in, including land not personally used? Yes No
If ‘No’, go to Part 4 on next page.
If ‘Yes’, please complete the details below and send us evidence of any income from this source, for
example, tenancy agreement or bank statements. Also, if it applies, please send us evidence of any costs
associated with the land or property, for example, receipts or invoices.
Medical Card and GP Visit Card Form MC1 7
MC1 June 2014
8 Medical Card and GP Visit Card Form MC1
Part 4 – Family expenses
A. Housing
Payment
expense
Rent
Mortgage
Mortgage
protecon
House
insurance
Frequency (for example, weekly,
monthly, yearly)
Documents to send to us
(Photocopies only please)
Up-to-date copy of tenancy
agreement or rent book
Recent mortgage account
statement or 3 months’
recent bank statements
showing mortgage payments
Recent cercaon from
provider conrming payment
Recent cercaon from
provider conrming payment
Amount
E
P
P
P
B. Childcare
Expenses on the following childcare arrangements are accepted: crèche, montessori, playgroup,
aer school facility, child minder, au pair and nanny
Weekly
amount
E
Type of childcare
(see examples above)
Name, address and telephone
number of childcare facility
Documents to send to us
(Photocopies only please)
Leer from
childcare provider
conrming payment
E
E
Locaon of
employment
You
Spouse
or
partner
Transport used
(for example, car,
bus, train)
If car, are you the
registered owner?
Yes No
Copy of vehicle
registraon cercate
or travel ckets
Copy of vehicle
registraon cercate
or travel ckets
If car, are you the
registered owner?
Yes No
Distance you
travel in
kilometres
each week
If public or shared
transport, cost
each week
Documents to send to us
(Photocopies only please)
C. Travel to work costs
MC1 June 2014
Medical Card and GP Visit Card Form MC1 9
D. Maintenance payments that you or your spouse or partner make to another person
Frequency of payment
(for example, weekly, fortnightly,
monthly or yearly)
Name and address of
the person who gets the payment
Amount
E
Copy of current
maintenance agreement or
leer from person you make
payment to conrming
amount being received and
frequency of payment
Documents to send to us
(Photocopies only please)
Part 4 – Family expenses ̶ connued
F. Medical expenses
Documents to send to us
(Photocopies only please)
Medical bills or invoices
and or payment receipts
If you and or any of your dependants has ongoing medical expenses or expenses related to a parcular illness,
please give details of the illness and the associated costs. If you want us to take these costs into account, you
must give us evidence of the costs (such as copies of bills, invoices and or receipts). Examples of expenses
include doctors’ or consultants’ fees, hospital charges, cost of prescribed medicines or appliances or any other
such
expenses.
Details of illness Expense costs €
Frequency of payment
(for example, weekly, fortnightly,
monthly or yearly)
Documents to send to us
(Photocopies only please)
Copy of most recent invoice
or leer from nursing home
Amount
E
E. Net cost of private nursing home care for you and or your spouse or partner
(that is, the full cost of nursing home care less any amount the health authority pays toward the cost)
Name and address of nursing home
If you don’t have enough room to complete this secon, please write addional details on a separate sheet
of paper and send it in with this form.
MC1 June 2014
10 Medical Card and GP Visit Card Form MC1
Part 5 – Declaraon and consent
Before compleng this part of the form, please take me to read and consider the following important informaon:
By law, anyone who deliberately gives false informaon on this form, or who deliberately withholds informaon
relevant to an assessment of eligibility for a Medical Card and GP Visit Card, could face a ne, imprisonment or both.
Also, by law, anyone who does not tell the HSE about a change in their circumstances that could aect their eligibility
for a Medical Card or a GP Visit Card could face a ne.
Where appropriate, the HSE reserves the right to review and modify Medical Card and GP Visit Card eligibility status
at any me.
Declaraon and consent
Please read these statements. If you agree with them, please complete and sign or mark the form below.
I apply for a Medical Card or a GP Visit Card for myself and, if it applies, my dependants.
I declare that the informaon I have given as part of this applicaon is correct to the best of my knowledge.
I agree to tell the HSE immediately about any changes that may aect my own or, if it applies, my dependants’
eligibility for health services.
I agree that the HSE, when assessing eligibility, may contact other Government Departments including the
Department of Social Protecon, the Revenue Commissioners and the Department of Jusce to conrm the
informaon I have given.
I authorise the HSE to deal directly with my nominated contact person (advocate), on all aspects of my applicaon,
which includes the sharing of personal sensive informaon.
Please sign here: Date:
D D M M Y Y Y Y
Part 5A – Nominated contact person (advocate)
You may nominate a designated contact person.
N.B. All correspondence and contact will be directed to the nominated contact person (advocate)
Nominated
contact person’s
name:
Telephone no.
Relaonship to
applicant:
Nominated contact person’s address:
If you are not able to sign, your mark should be made and witnessed. The witness should sign his or her
name and complete his or her address in spaces provided below.
Place your mark here: Signature of witness:
Date: Address of witness:
D D M M Y Y Y Y
Part 5B - Mark and signature of witness
MC1 June 2014
I agree to provide medical services to this applicant and his or her dependants, if any.
Signature of doctor: GMS STAMP HERE:
GMS no.
Date:
D D M M Y Y Y Y
Doctor’s name: Doctor’s pracce address:
Will your dependants (if you have
Yes No
any) aend this doctor?
Doctor’s name: Doctor’s pracce address:
Will your dependants (if you have
Yes No
any) aend this doctor?
MC1 June 2014
Part 6 – Doctor of choice
Part 6A – Doctor’s acceptance
Ask your doctor to complete this secon of the form
Part 7A – Doctor’s acceptance (for spouse or partner)
Ask your spouse’s or partner’s doctor to complete this secon of the form
Part 7 – Spouse’s or partner’s doctor of choice
I agree to provide medical services to this applicant and his or her dependants, if any.
Signature of doctor: GMS STAMP HERE:
GMS no.
Date:
If your spouse or partner requires a dierent doctor of choice, please complete Part 7 and ask their
doctor to complete Part 7A.
Complete Checklist on next page.
Medical Card and GP Visit Card Form MC1 11
D D M M Y Y Y Y
