Medical Card and GP Visit Card Application Form

Who should use this form?

Anyone applying for either a Medical Card or a GP Visit Card – you will be assessed for both.

Did you know the quickest way to apply for either a Medical Card or GP Visit Card is online?

Apply at www.mymedicalcard.ie 

How do I apply for a Medical Card or a GP Visit Card?

Step 1. Understand that this form is long, as we want to get the informaon we need to process

your applicaon as quickly as we can for you. You will have to complete the parts of the

form that apply to you. Parts 3 (unless you have dependent children), 4 and 5 do not

always apply.

The eight secons of the form are:

Part 1: Declaraon and consent (to read and sign)

Part 2: Personal details

Part 3: Your dependent children

Part 4: Applying under EU regulaons or UK agreement

Part 5: Income details

Part 6: Family expenses

Part 7: Doctor of choice / doctor’s acceptance of you or your partner or family

Part 8: Data Protecon Statement

Step 2. Know that we ask you for photocopies of documents and other evidence in this form,

so you need to note what you need to send us for yourself and or for others (if relevant)

along with your completed form. Please ck o evidences in the lile boxes provided

as you gather evidences for us. We ask you not to send original documents as we can’t

return them.

Step 3. Read the form and then start lling it in using a black ballpoint pen. Remember to sign

Part 1. Only include or name any child dependants who live with you full me on this

form.

Step 4. Get your doctor and your spouse or partner’s doctor to complete and stamp Part 8 of this

form. The doctor(s) must have a contract with the Health Service Execuve.

Step 5. Read Part 8 about your Data Protecon rights.

Step 6. Email your completed applicaon forms and copies of all the documents we ask for to:

PCRS.applica[email protected]. For further informaon on emailing your applicaon,

please see page 20 of the application form. Or, if you wish you can post your

completed application form and copies of all the documents to the Eligibility Unit,

PO Box 11745, Dublin 11.

Need help?

Read this page and the questions and answers (Q and A) on the next two pages for help. If you need

further help, please visit www.medicalcard.ie, email [email protected] or 0818 224478.

Medical Card and GP Visit Card

Applicaon Form

MC1

Medical Card and GP Visit Card Form MC1 1

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2 Medical Card and GP Visit Card Form MC1

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Q1. Who can apply for a Medical Card or a GP Visit card?

Anyone who is ‘ordinarily resident’ in the Republic of Ireland can apply. ‘Ordinarily resident’ means that you are

living here and intend to live here for at least one year.

Q2. How do I complete an Irish language applicaon form?

If you wish to complete an application form in Irish and receive all your correspondence in Irish, please contact

0818 224478 or visit www.hse.ie to download the Irish version.

Más mian leat foirm iarratais a chomhlánú i nGaeilge a

gus gach comhfhreagras i nGaeilge a fháil, déan teagmháil

le 0818 224478 chun iarratas a dhéanamh nó téigh chuig www.hse.ie

Q3. How do I qualify for a Medical Card or a GP Visit Card?

We will look at your household income aer tax, PRSI (pay-related social insurance) and the USC (Universal Social

Charge) have been deducted. We also look at expenses like:

• rent • mortgage • maintenance costs

• mortgage protecon • house insurance • nursing home

• childcare • travel to work costs

If the gure we see aer we take away expenses from your household income is less than the ‘qualifying income

limits’, you and your family dependants will be sent a card. Qualifying income limits are nancial guidelines you

would need to meet to qualify for a Medical Card or GP Visit Card.

You can nd further details on qualifying income limits on www.medicalcard.ie

Q4. If I get a Medical Card or a GP Visit Card, does it cover my

family too?

If your family income falls under the qualifying income limits, the card will cover:

• you

• your spouse or partner

• your children under 16 years of age

Children who are aged 16 to 25 will get a card if they are receiving weekly income less than €164, and living with you

or living away from you to aend school or college in the Republic of Ireland. They must ll out their own applicaon

form and send it to us.

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Q5. I am aged between 16 and 25. How do I apply?

How you apply depends on your income. See which applies to you from 1, 2 or 3 below.

1. Is your weekly income €164 or more? You must complete all relevant parts of this applicaon form.

2. Is your weekly income less than €164

and your parent(s) or guardian(s) do not have a current Medical Card? They

must complete all relevant parts of a separate applicaon form and send it to us with your fully completed form.

3. Is your weekly income less than €164

and your parents or guardians have a current Medical Card. You must

complete this applicaon form and include parents’ or guardians’ Medical Card number on page 7.

Q6. What if my household income is over the qualifying

income limits? (see Q3 on page 2 for denion)

If this is the case, you and your family dependants may be granted a Medical Card or a GP Visit Card where you have

dicult personal circumstances that cause you nancial pressure - for example, a family member with a chronic

illness. You need to send us evidence of these circumstances with your completed applicaon form, for example, a

medical report and medical expense receipts.

Q7. Will my savings and investments be taken into account

when assessing my income?

It depends. 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.

We will assess any savings or investments above these amounts.

Q8. How do I apply for a Medical Card under European (EU)

Regulaons?

You can apply for a Medical Card under EU Regulaons if you meet both of the following requirements. You and or

your spouse and dependants are:

• insured under the social security legislaon of another EU/EEA member state or Switzerland, so they are receiving

a social security pension from that state or working and paying social insurance in that state, and

• not subject to Irish social security legislaon. (You are subject to Irish social security legislaon if you are receiving a

contributory Irish social welfare payment based on PRSI contributors or if you are subject to PRSI in the Irish State.

PRSI is pay-related social insurance.)

If you meet the above requirements, you can claim your entlement to “Health Care under EU Regulaons”. See

Part 4.

4 Medical Card and GP Visit Card Form MC1

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If you are a froner or posted worker or pensioner or dependent on a person insured in another EU/EEA country

or Switzerland, you can apply for a medical card under EU Regulaons by:

• Compleng an online medical card applicaon and uploading your and / or your spouse and dependants S1 form

issued by the EU/EEA member state or Switzerland.

• Compleng parts 1, 2, 3, 4 and 8 (doctor to complete) of this paper applicaon and including a copy your and /or

your spouse and dependants S1 form issued by the EU/EEA member state or Switzerland.

If you are a froner or posted worker or pensioner or dependent on a person insured in United Kingdom, you can

apply for a medical card under EU Regulaons by:

• Compleng an online medical card applicaon and uploading a copy of a leer of old age pension conrmaon

from the Department for Works and Pensions Board (if you are a pensioner) or a recent payslip if employed

instead of an S1 form from the UK.

• Compleng parts 1, 2, 3, 4 and 8 (doctor to complete) of this paper applicaon and include a copy of a leer of old

age pension conrmaon from the Department for Works and Pensions Board (if you are a pensioner) or a recent

payslip if employed instead of an S1 form from the UK.

If your spouse or partner and dependants are not covered for Health Care under EU Regulaons but require Medical

Card Eligibility, you must complete this applicaon form in full.

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Part 1 – Declaraon and consent

Signature: Date:

M Y Y

Y Y

Sign

Here

✗

If you are not able to sign, your mark should be made below. Place your mark here:

Before compleng this part of the form, please read the following important informaon carefully. It is about

what it means when you give us informaon for your applicaon. Sign below where shown if you agree with the

informaon on this page – and add the date.

By law, anyone who deliberately gives false informaon on this form, or who deliberately withholds informaon

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 aect their

eligibility for a Medical Card or a GP Visit Card could face a ne.

Where appropriate, the HSE has the right to review and modify (change) Medical Card and GP Visit Card eligibility

status at any me.

Declaraon and consent

Please read these statements. If you agree with them, please complete and sign or mark the form below.

Statements:

• I/We declare that I/We are ordinarily resident in Ireland. “Ordinarily resident” means that you are living in

Ireland and intend to live here for more than one year.

• I/We apply for a Medical Card/GP Visit Card.

• I/We declare that the information given as part of this application is correct to the best of my/our knowledge.

• I/We agree that the HSE, when assessing eligibility, in the absence of supporting documentation will contact

other Government Departments including the Department of Employment Affairs and Social Protection

and Revenue through real time systems to confirm information that should be supplied as supporting

documentation.

• I/We agree to tell the HSE immediately of any changes that may affect my/our eligibility for health services.

• I/We agree that the HSE, when assessing eligibility, may contact other Government Departments including the

Department of Employment Affairs and Social Protection and Revenue to confirm the information that I/we

have given.

• I/We agree for a HSE PCRS Doctor to contact GPs or other doctors or other health professionals involved in

the care of people named on this application for further information relevant to the assessment of this

application.[PCRS stands for Primary Care Reimbursement Service. The service that deals with applications.]

• I/We agree to inform the Eligibility Unit of any change in my address or other personal data so that the HSE

can keep my personal data accurate and up to date.

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FOR OFFICIAL USE ONLY

Application No.:

Date Received:

For Parts 2, 3, 4, 5, 6 and 7 that apply

to you, please complete in CAPITAL

LETTERS and place a ck (

) where

appropriate in the single boxes

provided.

First name(s): Surname:

PPS number:

Birth surname:

(If dierent)

Date of birth: Gender: Male Female

Part 2 – Personal details (please use a black ballpoint pen to complete this form)

D D M M Y Y Y Y

Eircode: Mobile phone:

(We may text about this applicaon if mobile number is provided.)

Address:

Dayme phone:

Email address:

Naonality:

How long have you lived in Ireland?

Are you ordinarily resident in the Republic of Ireland Yes No (This means do you live here or plan

to live here for at least a year.)

Do you live alone? Yes No If No, who do you live with?

Are you:

Single Married Cohabing In a Civil Partnership Widowed Separated Divorced

Do you or your spouse/partner have, or ever had a Medical Card or a GP Visit Card? Yes No

If ‘Yes’, please ck the type of card and write in the number:

Applicant: Medical Card GP Visit Card Card number

Spouse: Medical Card GP Visit Card Card number

Are you aged 16-25?

Does your parent(s) or guardian have a Medical Card or a GP Visit Card? Yes No

(If yes, please provide their card number below.)

Card number:

Are you aending school or third level educaon?

Yes No

(Personal Public Service number)

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First name(s): Surname:

PPS number:

Date of birth: Gender: Male Female

Naonality:

How long have you lived in Ireland?

Are you ordinarily resident in Ireland? (Live here or plan to live here for at least a year) Yes No

Details for your spouse or partner

D D M M Y Y Y Y

First name(s): Surname:

PPS number: Gender: Male Female

Date of birth: In 2nd level educaon or 3rd level educaon

Relaonship to you: Receiving a 3rd level educaon grant: Yes No

D D M M Y Y Y Y

First name(s): Surname:

PPS number: Gender: Male Female

Date of birth: In 2nd level educaon or 3rd level educaon

Relaonship to you: Receiving a 3rd level educaon grant: Yes No

D D M M Y Y Y Y

First name(s): Surname:

PPS number: Gender: Male Female

Date of birth: In 2nd level educaon or 3rd level educaon

Relaonship to you: Receiving a 3rd level educaon grant: Yes No

D D M M Y Y Y Y

First name(s): Surname:

PPS number: Gender: Male Female

Date of birth: In 2nd level educaon or 3rd level educaon

Relaonship to you: Receiving a 3rd level educaon grant: Yes No

D D M M Y Y Y Y

Use a separate sheet of paper for addional children in this category

Part 3 – Your dependent children

Dependants who are aged 16-25 in school or college or receiving an income of less than €164 per week must

be included on this applicaon. They must also complete their own applicaon form. Please do not include

dependants who are living with another parent or guardian.

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4a. Employment – employed by another EU/EEA member state, Switzerland or UK.

Q. What do you need to provide if you are employed by another EU/EEA member state, Switzerland or

UK and applying under EU regulaons and you live now in the Republic of Ireland?

A. If you work as a froner or posted worker and you are employed by a company or organisaon based in

UK, you will need to provide your current payslip.

If you work as a froner or posted worker and you are employed by a company or organisaon based in

EU/EEA member state or Switzerland, you will need to provide E106 or S1 form.

If you are dependent on someone who lives in another EU/EEA member state, Switzerland or UK, you will

need to provide E109 or S1 form.

4b. Pension – geng a pension from another EU/EEA member state, Switzerland or UK.

Q. What do you need to provide if you are receiving a pension from another EU/EEA member state,

Switzerland or UK and applying under EU regulaons and you live now in the Republic of Ireland?

• If you are geng a state pension from the UK, you will need to provide a leer from the Department

of Works and Pensions (DWP) conrming this pension.

• If you are geng a pension from an EU/EEA member state or Switzerland, you will need to provide an

E121 or S1 form.

• If you are dependent on someone who lives in another EU/EEA member state, Switzerland or UK, you

will need to provide an E109 or S1 form.

EU/EEA or Switzerland UK Evidence

enclosed

Applicant E106 or S1 form

E109 or S1 form

Recent payslip

Spouse or partner E106 or S1 form

E109 or S1 form

Recent payslip

EU/EEA or Switzerland UK Evidence

enclosed

Applicant E121 or S1 form Department of Works and Pension

(DWP) Leer

Spouse or partner E109 or S1 form Department of Works and Pension

(DWP) Leer

Part 4 – Are you applying under EU or UK agreement

regulaons?

Only complete secons 4a and/or 4b if applying for Health Care under EU Regulaons, please read pages 3

and 4 for help and informaon.

Do you wish your spouse/partner and/or family to be means assessed for a Medical Card

if they do not qualify under EU Regulaons? Yes No

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Part 5 – Income details

(Please give details of all income that you and your spouse or partner receive)

A. Social Welfare Payment

Q. What do you and your spouse or partner (if any) need to provide if one or both of you receive a

social welfare payment?

A. If on sick leave, carer’s leave or maternity leave and not receiving any payment from an employer, you

and your spouse/partner (if relevant) must also send a leer from your employer(s) to conrm you are

not geng a payment.

If your or your spouse’s/partner’s employment ended aer 1 January 2019, you must print and send us

details of your ceased employment through “myAccount” services on Revenue’s website.

If either or both of you are sll being paid by an employer(s), you (or each of you) must send us a

photocopy of your most recent payslip(s).

Amount Payment frequency Name of payment

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

€

Spouse or

partner

€

10 Medical Card and GP Visit Card Form MC1

Wage (Aer

tax, PRSI and

USC deducted)

Payment frequency Employer name

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

€

Spouse or

partner

€

Scheme

type

Start date Expected nish date

Evidence

enclosed

Applicant

Scheme

type

Start date Expected nish date

Evidence

enclosed

Spouse or

partner

D D M M Y Y Y Y

B. Wages

Q. What do you and or your spouse or partner (if any) need to provide if one or both of you get wages?

A. You need to provide a photocopy of your most recent payslip (dated in the last 3 months). If your

employment ended aer 1 January 2019, you can print out details of that employment through

“myAccount” services on the Revenue website. If you have more than one employment, please provide a

payslip for each one.

C. Back to employment or educaon scheme (for example, Community Employment

Scheme)

Q. What do you and or your spouse or partner (if any) need to provide if one or both of you are on a

back to employment or educaon scheme?

A. You need to provide a leer(s) from the scheme supervisor(s) showing the start date and expected

nish date for you and/or your spouse or partner and a photocopy of your most recent payslip (dated in

the last 3 months).

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Medical Card and GP Visit Card Form MC1 11

Amount Type of employment

Evidence

enclosed

Applicant

€

Spouse or

partner

€

Amount Payment frequency Country that pays this

pension

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

Spouse or

partner

€

D. Self-employed

Q. What do you and or your spouse or partner (if any) need to provide if one or both of you are self-

employed?

A. All pages of your most recent Noce of Assessment (NOA) or your Acknowledgement of Self-

Assessment from Revenue. These pages should include a Revenue Indicave Calculaon (RIC). If the RIC

is not included in the correspondence from Revenue, you need to include a copy of your most recent

Income Tax Return (Form 11) which you sent to Revenue.

if Revenue advised you that you have No Net tax Liability (NNL) for your self-employment income, please

provide a set of accounts signed o by your accountant

if you have recently been assessed by Department of Social Protecon, please submit means assessment

completed by same

if your income from self-employment is listed on your Statement of Liability, please send us this statement

if your business is open less than one year, please provide a set of accounts signed o by your accountant

if your business has recently ceased trading, please conrm date of cessaon

E. A social security pension from another state

Q. What do you and your spouse or partner need to provide if one or both of you receive this kind of

pension?

A. You need to provide a photocopy of your most recent payslip(s) dated in the last 3 months or a leer

from a state authority showing the amount being paid within the last 12 months.

12 Medical Card and GP Visit Card Form MC1

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Amount

(Aer tax, PRSI

and USC

deducted)

Payment frequency Pension provider

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

€

Spouse or

partner

€

Amount Payment frequency Source of income

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

Spouse or

partner

€

F. A private or occupaonal pension

Q. What do you and your spouse or partner (if any) need to provide if one or both of you receive a

private or occupaonal pension?

A. You need to provide a photocopy of one of the following:

1) your most recent pension payslip dated within 12 months

2) a copy of your latest employment details summary which you can print out from “myAccount” services

on the Revenue website

3) a leer from pension provider conrming that pension is no longer being paid. If the pension was paid

in a lump sum, we need details of the lump sum paid from the pension provider.

G. Maintenance payment

Q. What do you or your spouse or partner (if any) need to provide if one or both of you receive a

maintenance payment?

A. Evidence of maintenance payment being received that is one of the following:

1) current court order or maintenance agreement. If the maintenance agreement is older than 12 months,

you must also send us evidence of the amount being paid, for example a bank statement dated within

last 3 months

2) signed leer from the person who pays the maintenance detailing the payment amount and frequency.

This leer must also be dated within the last 3 months

3) recent bank statement (dated within last 3 months and where account holder’s name is visible)

showing 3 or more maintenance payments being paid for at least 3 months, where it is clear that the

income is a maintenance payment

Feb 2024

Medical Card and GP Visit Card Form MC1 13

Current value

of savings and

shares invested

or held in

savings

Name and address of nancial

instuon where invested or

deposited

Type of savings or investments

Evidence

enclosed

€

H. Savings and investments

Do you or your spouse or partner (if any) have investments in stocks, shares or savings with banks or

building sociees or other nancial instuons?

Q. What do you need to provide?

A. Evidence of your savings and investments that is one of the following three opons:

1) recent statements of all accounts held in all nancial instuons showing details of current savings and

or investments

2) cercates of interest for all accounts held (dated within the last calendar year)

3) a copy of your current share cercates showing shareholdings if you hold stocks or shares.

If you don’t have enough room to complete this secon, please write addional details on a separate sheet of

paper and send these with this completed form.

14 Medical Card and GP Visit Card Form MC1

Full address

of property

and land

Details of land and property

(for example, number of

bedrooms, number of acres

or if it a commercial unit

menon this)

Yearly income or

value of property

or land

Yearly costs

(for example,

outstanding

mortgage)

Evidence

enclosed

€ €

Amount Payment frequency Source of income

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant

€

Spouse or

partner

€

I. Property addional to the family home

Read this secon if you or your spouse or partner (if any) own any property or land other than the house

you live in, including land not personally used. Please provide the evidence sought.

Q. What do you need to provide?

A. If your addional property (other than your principal private residence) is rented to another person,

you must send us the following documents:

Current tenancy agreement and a recent bank statement (dated within last 3 months and where account

holder’s name is visible) showing 3 or more lodgments of rental income received for at least 3 months in a

row

A valuaon form from a cered auconeer if your addional property is not currently rented.

If your addional property has any costs associated with it, for example mortgage and mortgage

protecon. Please provide evidence of those costs.

J. Do you receive any other income?

Q. What do you and or your spouse or partner need to provide if one or both of you have any other

income?

A. Evidence of your declared income (evidence we accept can be either a recent leer from the income

provider or a bank statement dated within last 3 months and where account holder’s name is visible

showing 3 or more payments of income being received).

Feb 2024

Medical Card and GP Visit Card Form MC1 15

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

Part 6 – Household expenses

When sending evidence of your family expenses to us, please send photocopies only please. Original

documents will not be returned.

A. Rent

Q. What evidence of rent do you need to provide?

A. You need to provide a photocopy of one of the following:

Your current tenancy agreement

Rent book

HAP (Housing Assistance Payment) agreement

Leer from landlord.

You also need to send us a recent bank statement (dated within last 6 months and where account holder’s

name is visible) showing payments of rent being paid for at least 3 months in a row.

If you are sending us a Rent book, it must be dated within last 6 months (where Tenants/Landlords

name is visible) showing rent being paid for at least 3 months in a row and signed by the landlord.

B. Mortgage

Q. What evidence of your mortgage payments do you need to provide?

A. You need to send us recent evidence of one of the following:

Bank statement (dated within last 6 months and where account holder’s name is visible) showing at least

3 payments in a row, where it is clear that the payment is for your mortgage

Mortgage account statement (dated within last 6 months and where account holder’s name is visible)

showing at least 3 mortgage payments in a row.

Leer from mortgage provider dated within last 3 months detailing the amount you repay and frequency

of payment.

Feb 2024

16 Medical Card and GP Visit Card Form MC1

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

C. Mortgage protecon

Q. What evidence of your mortgage protecon payments do you need to provide?

A. Leer from protecon provider detailing repayment amount and frequency (should be dated within

last 12 months)

Bank statement (dated within last 6 months and where account holders name is visible) showing at least 3

payments in a row, where it is clear that the payment is for mortgage protecon.

D. House insurance

Q. What evidence of your re and contents insurance do you need to provide?

A. Annual leer from insurance provider detailing repayment amount and frequency (should be dated

within last 12 months)

Recent bank statement (dated within last 6 months and where account holder’s name is visible) showing

at least 3 payments in a row, where it is clear that the payment is for re and contents insurance.

E. Childcare

Q. What do you need to provide?

A. Evidence of your expenses for childcare costs. This needs to be a leer, dated and signed within the last

3 months from your childcare provider detailing weekly or monthly cost.

If your child is covered under the Naonal Childcare Scheme, please provide conrmaon from your

childcare provider of the amount you pay aer the childcare subsidy has been deducted.

Childcare costs will only be considered if you and your spouse or partner (if applicable) are both working.

Feb 2024

Medical Card and GP Visit Card Form MC1 17

Address of employment Transport

used, for

example car,

bus or train

If you use

a car, ll in

the distance

you travel in

kilometers

each week

If you get

public

transport,

ll in the

weekly

costs

Evidence

enclosed

Applicant

Spouse or

partner

Amount Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

€

F. Travel to work costs

Q. What do you need to provide?

A. Evidence of your expenses you have for travel to work (if any). A copy of your Vehicle Registraon

Cercate or public transport ckets. Please conrm address of employment and distance travelled each

week in kilometers.

G. Maintenance costs (if relevant)

Q. What do you need to provide?

A. Evidence of maintenance payment being paid by you and or your spouse or partner.

Evidence we accept includes one of the following:

1) Current court order or maintenance agreement. If the maintenance agreement is older than 12

months, you must also send us evidence of the amount being paid, for example a bank statement dated

within last 3 months.

2) Signed leer from the person who receives the maintenance detailing the payment amount and

frequency. This leer must also be dated within the last 3 months.

3) Recent bank statement (dated within last 3 months and where account holder’s name is visible)

showing 3 or more payments of maintenance being paid for at least 3 months, where it is clear that the

income is a maintenance payment.

Feb 2024

18 Medical Card and GP Visit Card Form MC1

Name and address

of the nursing

home

Amount you pay Payment frequency

Evidence

enclosed

Weekly Fortnightly Monthly

Applicant €

Spouse or

partner

€

Details of illness Expense costs in the last

12 months

Evidence

enclosed

€

Other relevant medical informaon which you feel may help with your applicaon:

H. Nursing home costs

Q. What do you need to provide?

A. Evidence of the cost of what you pay for you and/or your partner’s or spouse’s private nursing home

care. This can be a leer from your nursing home detailing the cost of nursing home fees.

Evidence of the cost of private nursing home care and conrmaon of you and/or your partner’s or

spouse’s contribuon towards the Fair Deal Scheme. This evidence could be a leer from the nursing

home detailing cost and a leer from HSE outlining Fair Deal contribuon.

I. Medical expenses

Q. What do you need to provide?

A. Please give details of your illness or illnesses, and their costs. Please provide evidence of these costs

(bills, invoices and receipts)

Feb 2024

Medical Card and GP Visit Card Form MC1 19

If your spouse or partner requires a dierent doctor of choice, please have their GP complete Part 7A.

Doctor’s name: Doctor’s pracce address:

Will your dependants (if you have

any) aend this doctor?

I agree to provide General Medical Services to the above named (and or their dependants). This is in line

with my agreement with the HSE to provide services under Secon 58 of the Health Act 1970 and Health

Amendment Act 2005.

Signature of doctor: General Medical Services stamp here:

GMS no.

Date:

D D M M Y Y Y Y

Doctor’s name: Doctor’s pracce address:

I agree to provide General Medical Services to the above named (and or their dependants). This is in line

with my agreement with the HSE to provide services under Secon 58 of the Health Act 1970 and Health

Amendment Act 2005.

Signature of doctor: General Medical Services stamp here:

GMS no.

Date:

D D M M Y Y Y Y

Part 7

–

Doctor of Choice / Doctor’s acceptance

Ask your doctor and your spouse’s or partner’s doctor to complete the relevant information in this part of

the form.

Important: You will need to have a GP accept you as a patient on to their panel to get a GP visit card.

It can take time to find a GP who accepts new patients. If you cannot get your first choice of GP, try

another GP in your area.

You can find a list of GPs providing medical card and GP visit card services at www.medicalcard.ie

I agree to provide medical services to this applicant and their dependants, if any.

7A. Spouse’s or partner’s doctor of choice and their doctor’s

acceptance

Ask your spouse’s or partner’s doctor to complete the relevant informaon in this part of the form.

Feb 2024

Yes No

Will your dependants (if you have

any) aend this doctor?

Yes No

Medical Card and GP Visit Card Form MC1 20

Part 8: Data Protecon Noce

The HSE will treat all personal data you provide as part of this applicaon as condenal and store it

securely. When the HSE receives your completed applicaon form and any supporng documents, it will

make a computer record in your name(s). This record will contain the relevant personal informaon you

or your spouse/partner (if relevant) have supplied.

This rec

ord will be used and retained by the HSE, for the purposes of processing your Medical/GP Visit

Card applicaon. The HSE may also use details you provided to contact you or your spouse/partner

(if relevant) in relaon to eligibility under the Scheme, and/or in relaon to services received based

on eligibility awarded. The HSE will not disclose (share) to other people or organisaons the personal

informaon you have given unless permission has been given by the person to whom the informaon

relates or the HSE is required to do so by law.

The HSE’s priv

acy statement is available to use at www.hse.ie.

Feb 2024

PCRS is the Primary Care Reimbursement Service.

Remember to send your completed and signed form, along with photocopies of evidences needed to:

Eligibility Unit

PO Box 11745

Dublin 11

Did you know that instead of posng your applicaon and supporng documentaon, you can email

this to us at PCRS.Applica[email protected]

You can take photographs or scans of each page of your applicaon and these can be then

emailed to us. Can you please ensure the following:

1. The photo or sc

an is not blurry

2. The full page is captured with all gures/details visible

3. Email the supporng documentaon to PCRS.Applica[email protected]

We look forward to processing your applicaon as quickly as we can.