HSE Med Card Form (English) 8pg MC 1 Mc1

User Manual: MC 1

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Medical Card / GP Visit Card
Application Form - MC1
This is not an on-line form. Please print and complete

Date Received

Please read the back page help sheet carefully before you complete the form. Please use block capitals

Part 1A Applicant’s Details

First Name(s)
House Number / Name

Date of Birth
Address line 1
Address line 2

Contact Phone Number

Address line 3


Address line 4
Town / Postal Area
P.P.S.N. (RSI) No.
Do you live alone? Yes


If No, with whom do you live?

Your Birth Surname

Your Mother’s Birth Surname

E-mail Address:

Are You? (Please tick

as appropriate)

Married / Cohabiting

Do you hold or have you ever held a Medical Card?




Separated / Divorced


If ‘Yes’ please state: Who was the Issuing Authority?

Medical Card Number

Part 1B For Completion by persons aged 16-25 years
Are you financially dependant on your parents?



If you answer ‘No’ please complete parts 1a, 2, 3, 4, 5 and 6a of this form
If you answer ‘Yes’ please complete all parts of this form.

Parent (s) medical card number
Expiry Date
Where was it issued from?
Name of School / College being attended
Expected completion date of course

School / College Stamp

Child Benefit Claim Number:

16 years

16 years



Spouse /

First Name (s)

Surname (s)

What is your Spouse’s / Partner’s Birth Surname
Date of Birth

P.P.S. Number
(Formally RSI Number)


to you

What is your Spouse’s / Partner’s Mother’s Birth Surname?

Part 2 Details of your Spouse / Partner & any dependants
Does this person
have their own
Income and / or an
Maintenance Grant
(Please specify)

Part 3 Details of Income -

All Sections Must Be Completed
Please attach documentary evidence of Incomes.

A. What is your weekly gross income and that of your spouse / partner from the following sources?


Type of Payment

Spouse / Partner


Type of Payment


Social Welfare Payment(s)
Health Service Executive
Social Security Payments
(from a non E.U. State)
Social Security Payments
(from an E.U. State)

B. What is your weekly gross income and that of your spouse / partner from the following sources?


Spouse / Partner



Self Employment
Sick Pay / Income Protection Schemes
Occupational Pension (s)
Maintenance Payments
FAS Training Allowance
Any other source (s) PLEASE SPECIFY

C. Have you or your spouse / partner investments in stocks, shares, or deposits with Banks / Building Societies or other
Financial Institutions? Yes


If yes please provide details and evidence of Investments

Amount(s) Invested €

Where Invested

Income Earned Per Year €

D. Do you or your spouse / partner own any property (including land not personally used) other than the house you occupy?



If yes please give details and the annual Income received from the property.

Back To “Employment / Education” Schemes
Type of Scheme

Spouse / Partner

Date of Commencement

Expected Finishing Date

Part 4 Detail of Outgoings -

All Sections Must Be Completed
Please attach documentary evidence of outgoings.

A. Housing

Weekly / Monthly


Payable To



B. Travel Costs To Work
Place of Employment

Type of Transport Used

Weekly Cost


Total Kilometres
(Return Journey)

Spouse / Partner

C. Loans

e.g. Banks / Credit Union, Hire Purchase, Lease
Purpose of Loan

Expiry Date of Loan

Weekly Repayment


Loan 1
Loan 2
Loan 3

D. Maintenance Payments To Another Person
To whom
Amount €

per week

E. Please provide details and evidence of any other issues which you wish to be considered. (e.g. GP fees / prescribed drug
/ medicines / appliances, hospital charges and travel / accommodation costs associated with attending clinics / hospitals.)

F. Are any of your medical costs covered by Private Medical Insurance or Employment / Benevolent Fund Assisted
Schemes? Yes


If ‘Yes’ please provide details:

G. Are there any other circumstances or issues not included above which you wish to have considered
(e.g. money management issues or child care costs)?

Part 5 Declaration
I hereby apply for a Medical Card / GP Visit Card for myself and / my dependants as listed.
I have read the note below 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 any changes which may affect my eligibility for health services and that of my dependants.
I agree that the Health Service Executive and its agents may make any inquiries that they think fit for the purpose of
considering my eligibility and that of my dependants.

Signature of Applicant:

(a) A person who knowingly makes a false statement, conceals any material fact or produces a false document in support of
a claim is liable to a fine or to imprisonment for up to three months or both a fine and imprisonment under Section 75 Health
Act 1970 as amended by the Health (Amendment) Act 2005.
(b) 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 fine under Section 49 of Health Act 1970 as amended by the Health
(Amendment) Act 2005.

Help Sheet for Completion of
‘Medical Card / GP Visit Card’ Application Form (MC1)

Please read this help sheet carefully before completing your application.
Failure to answer all appropriate sections of the form and / or to include documentary evidence
may delay the processing of your application.

All applicants other than those who are aged 70 years or over should complete this form (MC1).
Applicants who are aged 70 years or over should complete form MC2.

1. The following is a list of the items for which documentary evidence is required:
- Personal Public Service Number(s) (formerly known as RSI numbers) for yourself,
spouse / partner and all dependants listed in part 2 of the form.
- All incomes listed in sections A,B,C and D of part 3 of the form.
- All outgoings listed in sections A,B,C,D,E and G of part 4 of the form.
- Commencement and expected completion dates of ‘Back to Employment / Education’ Schemes.

2. Part 5 should be read and signed when the form has been fully completed.

3. Part 6a should be completed and signed by the client. Part 6b should be completed and signed by the doctor
of choice.

- Completed all relevant parts and signed the form?
- Provided proof of P.P.S. No. (formally R.S.I. No.) for yourself, your wife, husband or partner and any dependants?
- Provided proof of all incomes and assets declared in part 3?
- Provided proof of all outgoings including loans, rents, mortgages, and other costs you declared in part 4?
- Signed part 5?
- Completed and signed part 6a
- Arranged for your doctor of choice to complete and sign part 6b

If you need further help with the completion of your application form please call the
local Health Office / Centre. Completed forms should be sent to your local Health
Office / Centre

Part 6: To Be Completed By Client & Doctor Of Choice
Part 6a - To be completed by Client

I have chosen Dr.
to be my General Practitioner for the provision of General Medical Services.
I reside ____ miles from his/her main centre of practice
Client’s Signature


Part 6b - To be completed by Doctor
I agree to provide General Medical Services (GMS) to the above named (and/or dependants), subject to elegibility, in
accordance with my agreement with the HSE for the provision of services under Section 58 of the Health Act 1970 as
amended by the Health (Amendment) Act 2005.
Signed (General Practitioner)
GMS Registered No.

Please place official GMS stamp here

For Official Use Only
Distance Code


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