Hse Medical Card And Gp Visit Card Application Form Page 4
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
124
Medical Card and GP Visit Card Form MC1
1C – If you are a person aged between 16 and 25 and if you have a weekly income of less
than €164, please complete this section
Does your parent(s) have a Medical Card or a GP Visit Card?
Yes
No
If ‘Yes’ and if you are living with your parent(s) or living away from parental home for purposes of attending
school or college, you only need to:
complete Parts 1A, 1C, 1D, 5 and 6 of this form,
•
ask your doctor of choice to complete Part 6A, and
•
tick the kind of card your parent(s) has and write in the number below.
•
Medical Card
GP Visit Card
Card Number
If ‘No’ and if you are living with your parent(s) or living away from parental home for purposes of attending
school or college, your parents must complete all parts of this form, listing you as a dependant aged 16-25.
1D - Attending school or third level college?
Are you in school or third level education?
Yes
No
If ‘Yes’, what is the name of your school or college?
When will you finish your course?
D D M M Y Y Y Y
Please ask your school or college to stamp this form.
School or college stamp:
Part 2 ̶ Your dependants
Your dependants aged under 16
First name
Surname
Date of birth
PPS number
Relationship
to you
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
MC1 May 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dmv-002 - Driver's License, Driver Authorization Card, Or Identification Card Application Form
Legal
Form Au-526 - Sales And Use Tax Refund Application Form For Purchases Made Under The "buy Connecticut" Provision
Financial
Related Categories
Parent category: Medical