Application Form For European Health Insurance Card (Ehic) printable pdf download

Application form for

2 The main applicant

European Health Insurance Card (EHIC)

Personal details

The quickest way to apply for a card is online at

Title

Mrs

Miss

Other

Surname

or by calling the EHIC Application Line on 0300 330 1350.

Forename(s)

How to complete this form

S U R N A M E

D D

M M

Y Y

Date of birth - must be over 16 years old

To help us to process your application quickly, please write clearly

National Insurance number (or NHS number - see below)

in BLOCK CAPITALS inside the boxes using black ink only.

As the main applicant, you can also apply on behalf of your partner and/or any dependent

NHS number (England and Wales), Community Health Index

children. For each applicant or family member you are applying for, you must complete all the

number (Scotland) or Health and Care number (Northern Ireland)

questions asked. For more detailed information, please visit

Name of Local Authority responsible for collecting Council Tax for your dwelling

1 Declaration - Read before signing

I declare that I have read and understood the eligibility requirement for receiving an EHIC from

the ‘Important Information’ on the separate sheet accompanying this application. I confirm

Nationality

that I will give correct and accurate information in relation to this application. I understand

If you are not a UK, EU/EEA or Swiss national, attach a copy of your visa or residence permit

and accept that if I provide NHS Business Services Authority (NHSBSA) with false or misleading

information my application may be delayed and I may be liable for criminal prosecution. I shall

Passport number

inform the NHSBSA if any of the information provided on this application changes. I confirm

Y Y

M M

How long have you lived in the UK?

Number of years

and

months

that the main applicant is ordinarily resident in the UK, meaning they are living in the UK on a

lawful basis and are properly settled for the time being, and that they are 16 or over.

Do you have any plans to study abroad or move abroad permanently within the next

I understand that should the main applicant have a change to residency status, move abroad

five years? Posted workers should answer ‘No’

Yes

to live or take up work abroad, then they may no longer be entitled to a UK EHIC. In these

D D

M M

Y Y

If ‘Yes’, what date do you expect to leave the UK?

circumstances the relevant authorities must be informed and, if required, all associated EHICs

returned. I understand that the EHIC card does not prove entitlement to NHS services or

EHIC Personal Identification Number (PIN)

U K

residency in the UK, and does not constitute proof of identity.

Only for replacement or renewal EHIC - the number is shown on your existing EHIC

If you use a UK EHIC to access healthcare abroad when you are no longer entitled to it, you

Current permanent address

may be liable for the full cost of all your treatment received.

House number (and/or house name)

I am the main applicant

Street

I am a representative for the main applicant

Town

Full name of representative

Relationship to main applicant

County

Postcode

Country

Permanent address of representative

If you are an organisation processing EHIC

applications on behalf of a customer, you

Contact phone number (inc. area code)

must state your full business name and

address, as well as Companies House

Data Protection Act 1998

registration or Charity number (if applicable).

The NHSBSA and Department of Health acting as joint Data Controllers, will only use the information

If you fail to provide this information the

application will not be processed.

provided on this form for processing and verifying your application for the EHIC. Your details, in relation

to this application, will be removed from our files no later than 24 months after the expiry of your EHIC.

We will not transfer your Personal Data outside of the European Economic Area. Your information may be

Signature

Date

disclosed to: The Department for Work and Pensions and HM Revenue and Customs for the purpose of

D D

M M

Y Y

validating EHIC applications and claims, and NHS Protect, Department of Health - International Division

and local authorities in order to prevent, detect and investigate fraud and errors. We may contact you to

discuss your application by any of the methods you have provided on the application. Further details are

available at

Application Form For European Health Insurance Card (Ehic)

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