Fillable Printable Medical Card and GP Visit Card Application Form - Health Service Executive
Fillable Printable Medical Card and GP Visit Card Application Form - Health Service Executive
Medical Card and GP Visit Card Application Form - Health Service Executive
Medical Card and GP Visit Card
Application Form Form MC1
Medical Cards allow people free access to a Family Doctor, prescribed approved medicine and
a range of other health services. GP Visit Cards allow people to visit a Family Doctor free of charge.
Please read these information pages carefully before fi lling in the application form.
You can then detach this page and return the application form to your Local Health Office. If you
need help to complete your application, please call or visit your Local Health Office or Health Centre,
or contact the HSE infoline on 1850 24 1850.
Who can apply for a Medical Card or GP Visit Card?
Anyone who is ordinarily resident in Ireland can apply for a Medical Card or GP Visit Card - families,
single people, even those working full-time or part-time. Ordinarily resident means that you have been
living here for at least one year or you intend to live here for at least one year.
Who should fi ll in this form?
This form should be used by people applying for either a Medical Card or GP Visit Card, including
persons aged 70 and over. The Health Service Executive (HSE) will assess you for
both cards at
the same time, so there is no need to specify which card you are applying for.
The form has lots of sections – do I need to fi ll in all of them?
The application form is divided into 7 sections, all of which are colour coded.
You should fill in all the sections that apply to you.
Part 1 Applicant’s details
Part 2 Details of your spouse/partner and any dependants
Part 3 Details of income
Part 4 Details of outgoings and expenses
Part 5 Details of the Doctor you have selected
Part 6 Declaration and Consent
Part 7 Doctors Acceptance (To be completed by Doctor)
How do I qualify for a Medical Card or GP Visit Card?
First, the HSE will test your means or income. We consider your income after tax and PRSI
is deducted. We also take account of rent, mortgage, childcare and travel to work costs.
If you have personal circumstances like chronic illness or certain financial pressures, the HSE
may grant Medical Cards or GP Visit Cards even if you are over the financial limits.
What do I need to include with my application form?
To support your application, you must provide the HSE with documentary evidence
of the information you provide on:
• PPS Number (e.g. tax cert, P60, P45, payslip, social welfare book)
• Total Household Income (e.g. payslip, social welfare book, notice of tax assessment)
• Outgoings (e.g. rent book, mortgage or bank statement, maintenance payments,
travel to work costs (include proof of car ownership, if appropriate), receipts for childcare costs)
• Commencement and expected completion dates of ‘Back to Employment / Education’ Schemes
• If you are claiming under E.U. Regulations, please enclose the relevant E Form from the other
European State.
PLEASE TURN OVER
45738 HSE Eastern MC1 Form.indd 1 20/10/2008 12:50:47
Applications in respect of person aged 70 and over should be sent to : HSE Primary Care
Reimbursement Service, Exit 5, M50, North Rd, Finglas, Dublin 11.
Medical Card and GP Visit Card Form MC1
If I get a Medical or GP Visit Card, does it cover my family too?
If your family means are within the income guidelines, the Card granted to you will cover you, your
partner/spouse and dependants under 16 years. Your children or dependants aged 16-25 years and
who are fi nancially dependent on you will also be granted a Medical Card. They must fi ll out their own
application form, like this one, but do not need to complete Parts 2, 3 or 4. They only need to complete
Sections 1A, 1B, 5, 6 and 7, and will be given their own card.
I have moved house, do I need to apply for a new card?
If you move house, you do not need to re-apply for a new Medical Card. You should make contact with
your Local Health Offi ce where your records will be updated and you will be advised of the GPs practising
in your new area of residence.
Does my Doctor have to sign the form?
A Family Doctor or GP must sign Part 7 of this form, agreeing to provide medical services to you and your
dependants. Contact your selected GP’s surgery and ask the doctor to sign your application form. A list
of GPs is available from your Local Health Offi ce.
I have fi lled in the form, what next?
When the form has been fully completed, read and sign Part 6 and look over the fi nal Checklist.
Completed forms should be sent to your Local Health Offi ce or Health Centre. A list of Local Health
Offi ces is provided on www.hse.ie or from the HSE infoline on 1850 24 1850.
How can I make sure my application is dealt with quickly?
To avoid delay in your application, please check you have fi lled in all the parts of the form that apply to
you, and that you have included all the documents requested. The HSE will contact you if any further
information is required.
Further information on Medical Cards and GP Visit Cards
is available in the HSE publication “YourGuideto”,
available on www.hse.ie or from your Local Health Offi ce
NOTE: If you are granted a GP Visit Card or deemed to be ineligible for a Medical/GP Visit Card,
you should also have a Drugs Payment Scheme (DPS) Card to ensure you only have to pay up
to a monthly limit for prescribed approved medication. Further information on the Drugs Payment
Scheme is available in the HSE publication “YourGuideto” available on www.hse.ie or from your
Local Health Offi ce.
School/college stamp
Part 1A – Applicant’s Details – Please use BLOCK CAPITALS
Surname:
Are you ordinarily resident in Ireland? Yes No
First Name(s): Address:
Date of Birth:
D D M M
Y Y Y Y
Daytime Phone:
0
Gender: Male Female
PPS Number:
Town:
E-mail address:
County:
Birth surname: :
(If different from above)
Mother’s birth surname:
Are you:
Married
Cohabiting Single Widowed Separated Divorced
Do you live alone? Yes No If ‘No’, who do you live with?
Do you hold or have you ever held a Medical Card / GP Visit Card? Yes No
If ‘Yes’, which Medical Card offi ce issued the card?
Card Number:
Part 1B –
Do your parents hold a Medical Card?
Yes No
Do your parents hold a GP Visit Card? Yes No
If ‘Yes’, which Medical Card offi ce issued the card?
Card Number:
If ‘No’, please contact your Local Health Offi ce for advice on how to apply. If you are aged 16-25 years and fi nancially
dependent on your parents, their income will determine your eligibility for a Medical Card or GP Visit Card.
Name of school /
college:
School / college stamp
Expected completion
date of course:
To be completed by people aged 16-25 years who are fi nancially dependent on their parents –
ignore Parts 2, 3 and 4, only complete Parts 1A, 1B, 5, 6 and 7 of this application form.
OFFICE USE ONLY
Medical Card and GP Visit Card Form MC1 Date Received
_ _ _ _
Card No.
_ _ _ _ _ _
45738 HSE Eastern MC1 Form.indd 3 20/10/2008 12:50:50
Part 2 – Details of your spouse / partner and any dependants
First Name(s)
Surname
Date of Birth PPS Number
Gender
Relationship
To you
Does this
person have
their own
income and /
or an
Educational
Maintenance
Grant
(please specify)
Spouse /
Partner
D D
M M
Y Y Y Y
M/F
Dependants
under 16
years
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
Dependants
over 16
years
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
Your spouse’s/partner’s birth surname
Your spouse’s/partner’s mother’s birth surname
Medical Card and GP Visit Card Form MC1
Part 3 – Details of income
Please attach documentary evidence of all income – Examples are given on page 1
Income should be given PER WEEK and AFTER tax and PRSI have been deducted
A. What is your weekly income and that of your spouse / partner from all sources?
Source
Applicant Amount
Type of Payment
Spouse / Partner
Amount
Type of Payment
Social Welfare
Payments /
Pensions
. .
Social Security
Payments from
an EU state
.
Issued from which
EU State: .
Issued from which
EU State:
Wages (after Tax
and PRSI)
. .
Self Employment
. .
Other (eg.
maintenance,
private pension)
. .
B. Back to Employment / Education Schemes e.g. Community Employment Scheme
Scheme Type Date Started Expected Finish Date
Applicant
D D M M
Y Y Y Y
D D M M
Y Y Y Y
Spouse / Partner
D D M M
Y Y Y Y
D D M M
Y Y Y Y
C. Have you or your spouse / partner investments in stocks, shares or deposits with
Banks / Building Societies or other Financial Institutions?
Yes No
If ‘Yes’, please provide details and evidence of investments.
Amount(s) invested Where Invested
D. Do you or your spouse / partner own any property (including land not personally
used) other than the house you occupy?
Yes No
If ‘Yes’, please provide details and the annual income received from the property.
Medical Card and GP Visit Card Form MC1
45738 HSE Eastern MC1 Form.indd 4 20/10/2008 12:50:53
Part 2 – Details of your spouse / partner and any dependants
First Name(s)
Surname
Date of Birth PPS Number
Gender
Relationship
To you
Does this
person have
their own
income and /
or an
Educational
Maintenance
Grant
(please specify)
Spouse /
Partner
D D
M M
Y Y Y Y
M/F
Dependants
under 16
years
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
Dependants
over 16
years
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
D D
M M
Y Y Y Y
M/F
Your spouse’s/partner’s birth surname
Your spouse’s/partner’s mother’s birth surname
Medical Card and GP Visit Card Form MC1
Part 3 – Details of income
Please attach documentary evidence of all income – Examples are given on page 1
Income should be given PER WEEK and AFTER tax and PRSI have been deducted
A. What is your weekly income and that of your spouse / partner from all sources?
Source
Applicant Amount
Type of Payment
Spouse / Partner
Amount
Type of Payment
Social Welfare
Payments /
Pensions
. .
Social Security
Payments from
an EU state
.
Issued from which
EU State: .
Issued from which
EU State:
Wages (after Tax
and PRSI)
. .
Self Employment
. .
Other (eg.
maintenance,
private pension)
. .
B. Back to Employment / Education Schemes e.g. Community Employment Scheme
Scheme Type Date Started Expected Finish Date
Applicant
D D M M
Y Y Y Y
D D M M
Y Y Y Y
Spouse / Partner
D D M M
Y Y Y Y
D D M M
Y Y Y Y
C. Have you or your spouse / partner investments in stocks, shares or deposits with
Banks / Building Societies or other Financial Institutions?
Yes No
If ‘Yes’, please provide details and evidence of investments.
Amount(s) invested Where Invested
D. Do you or your spouse / partner own any property (including land not personally
used) other than the house you occupy?
Yes No
If ‘Yes’, please provide details and the annual income received from the property.
Medical Card and GP Visit Card Form MC1
45738 HSE Eastern MC1 Form.indd 5 20/10/2008 12:50:54
Part 4 – Details of outgoings and expenses
• Please attach documentary evidence of all outgoings and expenses – Examples are given on page 1
A. Housing
Amount Frequency Payable to
Rent / Mortgage
.
Weekly / Monthly
Home Improvement
Loans
.
Weekly / Monthly
Mortgage Protection
.
Weekly / Monthly
House Insurance
.
Weekly / Monthly
B. Childcare
Weekly Amount Name & Address of Crèche / Child Minder
.
C. Travel to Work
Costs
Location of
Employment
Transport Used Total
Weekly Km
If Public or Shared
transport: Weekly Cost
Applicant
.
If car, are you the
registered owner?
Yes No
Spouse / Partner
.
If car, are you the
registered owner?
Yes No
If you own a car, please include a copy of the Vehicle Registration Certifi cate with your application.
D. Maintenance
payments
to another
person
Weekly Amount Name & Address to whom payments are made
.
E. If your income is above the income guidelines, you may still be granted a Medical Card or
GP Visit Card if you have exceptional circumstances that cause you undue fi nancial hardship.
Please provide details and evidence of any other issues which you wish to have considered.
Examples would include:
• Health Expenses including
professional fees
• Prescribed Medicines or Appliances
• Hospital Charges
• Travel, Accommodation or
Childcare costs related to
attending clinics or hospitals
• Loans or other money
management issues
Medical Card and GP Visit Card Form MC1 Medical Card and GP Visit Card Form MC1
Part 5 – Doctor of Choice
Doctor’s Name Practice Address
Miles from your home to Doctor’s main
centre of practice
Part 7 – Doctor’s Acceptance
I agree to provide Medical Services to this applicant and/or their dependants.
Signature of Doctor:
GMS STAMP HERE:
Part 6 – Declaration and Consent
(a) To process your application, the HSE may seek limited access to Social Welfare data to confi rm
details of you and your dependants, if any. The HSE may also seek limited access to Social Welfare
fi nancial details relevant to this application and further reviews. Your signature below shows that you
consent to this access.
(b) A person who knowingly makes a false statement, fails to disclose any material fact or produces a
false document as part of this application is liable to a fi ne and/or to imprisonment under Section 75
of the Health Act 1970 as amended by the Health (Amendment) Act 2005.
(c) A person who fails to notify the Health Service Executive of a change in circumstances which would
affect their eligibility for a Medical Card / GP Visit Card is liable to a fi ne under Section 49 of the Health
Act 1970 as amended by the Health (Amendment) Act 2005.
I hereby apply for a Medical Card / GP Visit Card for myself and my dependants as listed. I have
read the above notes and I declare that the information given by me on this form is to the best of my
knowledge and belief correct. I agree to immediately report to the HSE any changes which may affect
my eligibility for health services and that of my dependants.
Signature of Applicant:
Dated:
D D / M M /
Y Y Y Y
Dated:
D D / M M /
Y Y Y Y
45738 HSE Eastern MC1 Form.indd 6 20/10/2008 12:50:56
Part 4 – Details of outgoings and expenses
• Please attach documentary evidence of all outgoings and expenses – Examples are given on page 1
A. Housing
Amount Frequency Payable to
Rent / Mortgage
.
Weekly / Monthly
Home Improvement
Loans
.
Weekly / Monthly
Mortgage Protection
.
Weekly / Monthly
House Insurance
.
Weekly / Monthly
B. Childcare
Weekly Amount Name & Address of Crèche / Child Minder
.
C. Travel to Work
Costs
Location of
Employment
Transport Used Total
Weekly Km
If Public or Shared
transport: Weekly Cost
Applicant
.
If car, are you the
registered owner?
Yes No
Spouse / Partner
.
If car, are you the
registered owner?
Yes No
If you own a car, please include a copy of the Vehicle Registration Certifi cate with your application.
D. Maintenance
payments
to another
person
Weekly Amount Name & Address to whom payments are made
.
E. If your income is above the income guidelines, you may still be granted a Medical Card or
GP Visit Card if you have exceptional circumstances that cause you undue fi nancial hardship.
Please provide details and evidence of any other issues which you wish to have considered.
Examples would include:
• Health Expenses including
professional fees
• Prescribed Medicines or Appliances
• Hospital Charges
• Travel, Accommodation or
Childcare costs related to
attending clinics or hospitals
• Loans or other money
management issues
Medical Card and GP Visit Card Form MC1 Medical Card and GP Visit Card Form MC1
Part 5 – Doctor of Choice
Doctor’s Name Practice Address
Miles from your home to Doctor’s main
centre of practice
Part 7 – Doctor’s Acceptance
I agree to provide Medical Services to this applicant and/or their dependants.
Signature of Doctor:
GMS STAMP HERE:
Part 6 – Declaration and Consent
(a) To process your application, the HSE may seek limited access to Social Welfare data to confi rm
details of you and your dependants, if any. The HSE may also seek limited access to Social Welfare
fi nancial details relevant to this application and further reviews. Your signature below shows that you
consent to this access.
(b) A person who knowingly makes a false statement, fails to disclose any material fact or produces a
false document as part of this application is liable to a fi ne and/or to imprisonment under Section 75
of the Health Act 1970 as amended by the Health (Amendment) Act 2005.
(c) A person who fails to notify the Health Service Executive of a change in circumstances which would
affect their eligibility for a Medical Card / GP Visit Card is liable to a fi ne under Section 49 of the Health
Act 1970 as amended by the Health (Amendment) Act 2005.
I hereby apply for a Medical Card / GP Visit Card for myself and my dependants as listed. I have
read the above notes and I declare that the information given by me on this form is to the best of my
knowledge and belief correct. I agree to immediately report to the HSE any changes which may affect
my eligibility for health services and that of my dependants.
Signature of Applicant:
Dated:
D D / M M /
Y Y Y Y
Dated:
D D / M M /
Y Y Y Y
45738 HSE Eastern MC1 Form.indd 7 20/10/2008 12:50:57
Checklist – Have you:
Completed all relevant parts and signed the form?
Provided proof of PPS Numbers for you, your spouse / partner and any dependants?
Provided proof of all income and assets declared in Part 3?
Provided proof of all outgoings including rent / mortgage, childcare, travel to work costs
and any other costs you declared in Part 4?
Provided proof of car ownership, if appropriate?
Provided the relevant E Form if you are claiming under E.U. Regulations?
Read and signed Part 6?
Part 7 signed and stamped by your selected Family Doctor?
Medical Card and GP Visit Card Form MC1
45738 HSE Eastern MC1 Form.indd 8 20/10/2008 12:50:58
Applications in respect of persons aged 70 and over should be sent to : HSE, Primary
Care Reimbursement Service, Exit 5, M50, North Road, Finglas, Dublin 11.
