Health Service Executive Form Mc 2 - Medical Card Application Form (Page 2 of 2) in pdf

Health Service Executive Form Mc 2 - Medical Card Application Form Page 2

Are You? (Please tick as appropriate)

Married / Cohabiting

Single

Widowed

Separated / Divorced

Are you in receipt of a Social Security Pension from another EU member state? ___________

If yes, which EU Member State? __________________

Please give the distance in miles from your home to your Doctor’s main centre of practice __.

Data Protection Declaration: Please read and sign:

I agree that the Health Service Executive may access the Department of Social and Family

Affairs computer records/data for the purpose of verifying my age.

Signed: _________________________________Date: ________________________

Doctor’s Acceptance (to be completed by your Doctor)

I agree to provide General Medical Services to the above named, subject to eligibility, 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: ______________________________

Please place Official GMS stamp here

Date: ______________________________

Declaration

I hereby apply for a Medical Card. I am ordinarily resident in Ireland and I am aged over 70

years. I have read the introductory note above below and I declare that the information given

by me on this form is to the best of my knowledge and belief correct.

Signature of Applicant: _________________________

Date:

_________________________

Office Use Only

Date Application Received: ________________

Approved by:

_______________________

Date Approved: ________________

Card No

__________________

Card Expiry date _________________

Health Service Executive Form Mc 2 - Medical Card Application Form Page 2