Medical Card and GP Visit Card Application Form - Health Service Executive

Medical Card and GP Visit Card
Application Form Form MC1
Medical Cards allow people free access to a Family Doctor, prescribed approved medicine and
a range of other health services. GP Visit Cards allow people to visit a Family Doctor free of charge.
Please read these information pages carefully before fi lling in the application form.
You can then detach this page and return the application form to your Local Health Office. If you
need help to complete your application, please call or visit your Local Health Office or Health Centre,
or contact the HSE infoline on 1850 24 1850.
Who can apply for a Medical Card or GP Visit Card?
Anyone who is ordinarily resident in Ireland can apply for a Medical Card or GP Visit Card - families,
single people, even those working full-time or part-time. Ordinarily resident means that you have been
living here for at least one year or you intend to live here for at least one year.
Who should fi ll in this form?
This form should be used by people applying for either a Medical Card or GP Visit Card, including
persons aged 70 and over. The Health Service Executive (HSE) will assess you for
both cards at
the same time, so there is no need to specify which card you are applying for.
The form has lots of sections – do I need to fi ll in all of them?
The application form is divided into 7 sections, all of which are colour coded.
You should fill in all the sections that apply to you.
Part 1 Applicant’s details
Part 2 Details of your spouse/partner and any dependants
Part 3 Details of income
Part 4 Details of outgoings and expenses
Part 5 Details of the Doctor you have selected
Part 6 Declaration and Consent
Part 7 Doctors Acceptance (To be completed by Doctor)
How do I qualify for a Medical Card or GP Visit Card?
First, the HSE will test your means or income. We consider your income after tax and PRSI
is deducted. We also take account of rent, mortgage, childcare and travel to work costs.
If you have personal circumstances like chronic illness or certain financial pressures, the HSE
may grant Medical Cards or GP Visit Cards even if you are over the financial limits.
What do I need to include with my application form?
To support your application, you must provide the HSE with documentary evidence
of the information you provide on:
PPS Number (e.g. tax cert, P60, P45, payslip, social welfare book)
Total Household Income (e.g. payslip, social welfare book, notice of tax assessment)
Outgoings (e.g. rent book, mortgage or bank statement, maintenance payments,
travel to work costs (include proof of car ownership, if appropriate), receipts for childcare costs)
Commencement and expected completion dates of ‘Back to Employment / Education’ Schemes
If you are claiming under E.U. Regulations, please enclose the relevant E Form from the other
European State.
PLEASE TURN OVER
45738 HSE Eastern MC1 Form.indd 1 20/10/2008 12:50:47
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