HSE Med Card Form (English) 8pg MC 1 Mc1
User Manual: MC 1
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Page Count: 7
Part 1A Applicant’s Details
First Name(s)
House Number / Name
Address line 1
Address line 2
Address line 3
Address line 4
Town / Postal Area
County
Do you live alone? If No, with whom do you live?
Your Birth Surname
E-mail Address:
Are You? (Please tick as appropriate) Married / Cohabiting Single Widowed Separated / Divorced
Do you hold or have you ever held a Medical Card? Yes No
If ‘Yes’ please state: Who was the Issuing Authority?
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.
Medical Card / GP Visit Card
Application Form - MC1
Date Received
Yes No
Yes No
Date of Birth
Contact Phone Number
Surname(s)
Male Female
P.P.S.N. (RSI) No.
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
Please read the back page help sheet carefully before you complete the form. Please use block capitals
This is not an on-line form. Please print and complete
manually.
Your Mother’s Birth Surname
Medical Card Number
Part 2 Details of your Spouse / Partner & any dependants
What is your Spouse’s / Partner’s Birth Surname What is your Spouse’s / Partner’s Mother’s Birth Surname?
Child Benefit Claim Number:
First Name (s) Surname (s) Sex
M / F
Relationship
to you
Does this person
have their own
Income and / or an
Educational
Maintenance Grant
(Please specify)
Spouse /
Partner
Dependants
Under
16 years
Dependants
Over
16 years
Date of Birth P.P.S. Number
(Formally RSI Number)
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?
B. What is your weekly gross income and that of your spouse / partner from the following sources?
C. Have you or your spouse / partner investments in stocks, shares, or deposits with Banks / Building Societies or other
Financial Institutions? If yes please provide details and evidence of Investments
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.
E. Back To “Employment / Education” Schemes
Source Yourself Type of Payment Spouse / Partner Type of Payment
€€
Social Welfare Payment(s)
Health Service Executive
Payment(s)
Social Security Payments
(from a non E.U. State)
Social Security Payments
(from an E.U. State)
Source Yourself Spouse / Partner
€€
Wages
Self Employment
Sick Pay / Income Protection Schemes
Occupational Pension (s)
Maintenance Payments
FAS Training Allowance
Any other source (s) PLEASE SPECIFY
Amount(s) Invested €Where Invested Income Earned Per Year €
Type of Scheme Date of Commencement Expected Finishing Date
Self
Spouse / Partner
Yes No
Yes No
Part 4 Detail of Outgoings - All Sections Must Be Completed
Please attach documentary evidence of outgoings.
A. Housing
B. Travel Costs To Work
C. Loans e.g. Banks / Credit Union, Hire Purchase, Lease
D. Maintenance Payments To Another Person
To whom
Address
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 No
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)?
Rent
Mortgage
Amount Weekly / Monthly Payable To
€€
Yourself
Spouse / Partner
Place of Employment Type of Transport Used Weekly Cost Total Kilometres
€(Return Journey)
Loan 1
Loan 2
Loan 3
Purpose of Loan Expiry Date of Loan Weekly Repayment
€
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:
Date:
NOTE
(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.
CHECKLIST - Have You:
- 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
Name
Address
I have chosen Dr.
of
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 Date
Part 6b - To be completed by Doctor
ACCEPTANCE OF ELIGIBLE PERSON
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.
Date
For Official Use Only
Distance Code
Please place official GMS stamp here
