Health Service Executive Form Mc 2 - Medical Card Application Form
ADVERTISEMENT
1
2Health Service Executive
Form MC 2 - MEDICAL CARD APPLICATION FORM
FOR PEOPLE AGED 70 YEARS AND OVER
People aged 70 years and over and ordinarily resident in Ireland are automatically entitled to
a full Medical Card. If you are 70 years or over, and do not already hold a medical card, you
may apply for your medical card using this form.
If you have a spouse or other dependant aged 70 years or more should complete a separate
application form like this one.
If you are aged 70 or over, and have a spouse or other dependant(s) aged under 70 years,
they should apply using the standard Medical Card / GP Visit Card application form, MC1. As
their spouse, your means will be assessed during their application but you will still be entitled
to your own Medical Card.
Please complete part A of this form.
Bring it along to your Doctor of choice to have him/her fill in part B of the form marked
Doctor’s Acceptance.
Completed forms should be sent to your local Health Office or your Health Centre.
If you need any help completing this form, please call your Local Health Office or Health
Centre, or phone the HSE Information Line on 1850 24 1850.
MEDICAL CARD APPLICATION MC 2
PERSONS AGED 70 YEARS AND OVER
A Please use block capitals
First Name(s) ______________________Surname(s) _________________________
Address Line 1____________________________
(Please tick)
Male
Female
Address Line 2 ____________________________
Address Line 3 ___________________________
Email ________________________
Address Line 4____________________________
County
_____________________________
Contact Phone No ___
_________
P.P.S.N. (RSI) Number ___________________________
Do you hold or have you ever held a Medical Card?
Yes
No
(If yes) Card Number ______________
Previous Address(s)_________________________
_________________________
_________________________
_________________________
Date of Birth (DD/MM/YYYY
_____________________________
If married, please give your Maiden Name_____________________
Please giver your Mother’s Maiden Name _____________________
PLEASE TURN OVER
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical