Who should use this form?

Anyone applying for either a Medical Card or a GP Visit Card you will be assessed for both.
How do I apply for a Medical Card or a GP Visit Card?
Step 1. Complete this form. Read this page and the next page for help.
Step 2. Include all the documents we ask for in Part 3 and Part 4. Please send photocopies only.
SLep 3. 8ead and slgn Lhe declarauon ln arL 3.
Step 4. Ask your doctor of choice to complete Part 6A and, if appropriate, ask your spouses or partners doctor
to complete Part 7A.
SLep 3. 8ead and uck Lhe checkllsL on page 12.
SLep 6. Send Lhe compleLed appllcauon form and coples of all the documents we ask for, to:
C||ent keg|stranon Un|t, C 8ox 1174S, I|ng|as, Dub||n 11.
What can I do to avoid delaying the process?
lf you send us a fully compleLed form and all Lhe documenLs we ask for, we wlll deal wlLh your appllcauon qulckly
and wlll leL you know wlLhln 13 worklng days lf you are enuLled Lo a card. So Lo avold delay, ensure Lo do Lhe
following:
- Lake care Lo ll ln all your deLalls correcLly,
- lnclude coples of all Lhe documenLs we ask for ln arL 3 and arL 4, and
- make sure Lhe documenLs you send us are up Lo daLe.
lf you do noL lnclude all Lhe lnformauon we ask for, we wlll have Lo wrlLe Lo you for Lhe mlsslng lnformauon.
Need help?
8ead Lhls page and Lhe nexL page for help. lf you need furLher help compleung Lhls form, phone
Ca||save 1890 2S2 919 or vlslL your Loca| nea|th Cmce.
MC1 Sept 2013
Medical Card and GP Visit Card
App||canon Iorm
MC1
Medical Card and GP Visit Card Form MC1 1
2 Medical Card and GP Visit Card Form MC1
ne|p and |nformanon
MC1 Sept 2013
Who can apply for a Medical Card or a GP Visit Card?
Anyone who is ordinarily resident in the Republic of Ireland
can apply - famllles, slngle people, even Lhose worklng full
or parL ume. 'Crd|nar||y res|dent' means LhaL you are llvlng
here and lnLend Lo llve here for aL leasL one year.
I am aged between 16 and 2S. now do I app|y?
1. lf you have a weekly lncome of |ess than 164 and
you are elLher llvlng wlLh your parenL(s) or llvlng away
from Lhelr home auendlng school or college, and your
parenL(s) has a Medical Card or a GP Visit Card, you
musL compleLe arLs 1A, 1C, 1u, 3, and 6 of Lhls form.
Your doctor of choice must complete Part 6A.
2. lf you have a weekly lncome of |ess than 164 a week
and you are elLher llvlng wlLh your parenL(s) or llvlng
away from Lhelr home auendlng school or college, and
your parenL(s) dont have a Medlcal Card or a C vlslL
Card, your parent(s) must complete all parts of this
form.
3. lf you have a weekly lncome of 164 or more, you must
complete all parts of this form.
4. lf you llve away from your parenLal home for any reason
oLher Lhan auendlng school or college, you musL
complete all parts of this form.
How do I qualify for a Medical Card or a GP Visit Card?
llrsLly, we wlll look aL your household lncome aer Lax,
8Sl and Lhe unlversal Soclal Charge (uSC) have been
deducted. We also take rent, mortgage, childcare and
Lravel Lo work cosLs lnLo accounL. lf Lhe resulung gure ls
less Lhan Lhe lncome quallfylng llmlLs, you and your famlly
dependants will be issued with a card.
lor lnformauon on Lhe currenL lncome quallfylng llmlLs
that apply to your family size, Ca||save 1890 2S2 919 or
see our website www.med|ca|card.|e.
W||| my sav|ngs and |nvestments be taken |nto
account when assessing my income for Medical Card or
G V|s|t Card e||g|b|||ty?
We w||| not take |nto account savlngs or lnvesLmenLs of
amounts:
- up Lo t36,000 for a slngle person, or
- up Lo t72,000 for a couple.
Also, we w||| not take |nto account any amounL recelved
from cerLaln sLaLe sponsored compensauon or redress
schemes or any lnLeresL earned on Lhe lnvesLmenL of Lhese
funds.
lor lnformauon on Lhe speclc compensauon or redress
schemes covered by Lhls secuon, please see
www.med|ca|card.|e or phone Ca||save 1890 2S2 919.
What if my household income is over the qualifying
limits?
If this is the case, you and your family dependants may
be granLed a Medlcal Card or a C vlslL Card lf you have
dlmculL personal clrcumsLances LhaL cause you nanclal
pressure - for example a family member with a chronic
lllness. ?ou need Lo send evldence wlLh your compleLed
appllcauon form ln supporL of Lhese clrcumsLances,
for example, a medical report and or medical expense
receipts.
If I get a Med|ca| Card or a G V|s|t Card, does |t cover my
family too?
lf your famlly lncome falls wlLhln Lhe quallfylng lncome
llmlLs, Lhe card wlll cover you, your spouse or parLner, and
your children under 16 years of age.
lf your chlldren are aged 16 Lo 23 and are recelvlng weekly
lncome less Lhan t164, and llvlng wlLh you or llvlng away from
you Lo auend school or college, Lhey wlll also geL a card. 1hey
musL ll ouL Lhelr own appllcauon form and send lL Lo us Lo
recelve a card.
How do I qualify for a Medical Card under European
Un|on (LU) kegu|anons?
?ou wlll quallfy for a Medlcal Card under Lu 8egulauons lf
you meet all of Lhe followlng requlremenLs:
- you are ordlnarlly resldenL ln Lhe 8epubllc of lreland,
- you are lnsured under Lhe soclal securlLy leglslauon
of anoLher Lu/LLA member sLaLe or SwlLzerland, LhaL
means recelvlng a soclal securlLy penslon from LhaL
state or working and paying social insurance in that
state, and
- you are noL sub[ect Lo lrlsh soclal securlLy leglslauon
- you are sub[ecL Lo lrlsh soclal securlLy leglslauon lf
you are recelvlng a contr|butory Irish social welfare
payment or if you are subject to PRSI in the Irish state.
lf you meeL Lhe above requlremenLs, you can clalm your
enuLlemenL Lo a Medlcal Card by sendlng us:
- a compleLed appllcauon form, and
- Lhe relevanL L or S form lssued by Lhe Lu/LLA
member sLaLe (or SwlLzerland) you are lnsured wlLh.
uk lnsured persons applylng under Lu 8egulauons should
send us a leuer of conrmauon from Lhe uk enslons
8oard or a recenL paysllp (lf employed ln uk) ln place of
Lhe L or S form.
Medical Card and GP Visit Card Form MC1 3
MC1 Sept 2013
FOR OFFICIAL USE ONLY
Application No.:
Date Received:
1A - our deta||s
llrsL name(s): Surname:
Date of birth:
Birth surname:

(lf dlerenL)
PPS number: Gender: Male Female
Address:
Mobile phone:
(lf you enLer your moblle phone we may LexL you ln connecuon wlLh
your appllcauon)
uayume phone:
CounLry of blrLh: Lmall address:
Pow long have you llved ln lreland?
Are you ordlnarlly resldenL ln lreland? (See Lop of page 2 for denluon of 'ordlnarlly resldenL'.) Yes No
uo you llve alone? ?es no
If No, who do you llve wlLh?
Are you:
Slngle Marrled Cohablung ln a Clvll arLnershlp Wldowed SeparaLed ulvorced
uo you have, or have you ever had, a Medlcal Card or a C vlslL Card? ?es no
If 'es', please uck Lhe klnd of card and wrlLe ln Lhe number:
Medical Card GP Visit Card Card Number
art 1 - ersona| deta||s
18 - Deta||s for your spouse or partner (If you don't have a spouse or partner, p|ease go to next page)
llrsL name(s): Surname:
Date of birth:
Birth surname:

(lf dlerenL)
PPS number: Gender: Male Female
ls your spouse or parLner ordlnarlly resldenL ln lreland? ?es no
uoes your spouse or parLner have, or has he or she ever had, a Medlcal Card or a C vlslL Card? ?es no
If 'es', please uck Lhe klnd of card and wrlLe ln Lhe number:
Medical Card GP Visit Card Card Number
D D M M Y Y Y Y
D D M M Y Y Y Y
Ior arts 1, 2, 3, 4, 6 and 7 that app|y
to you, p|ease comp|ete |n CAI1AL
LL11LkS and p|ace a nck ( ) where
appropr|ate |n the s|ng|e boxes
prov|ded.
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
4 Medical Card and GP Visit Card Form MC1
MC1 Sept 2013
1C - If you are a person aged between 16 and 2S and |f you have a week|y |ncome of |ess
than 164, p|ease comp|ete th|s secnon
uoes your parenL(s) have a Medlcal Card or a C vlslL Card? ?es no
If 'es' and lf you are llvlng wlLh your parenL(s) or llvlng away from parenLal home for purposes of auendlng
school or college, you only need to:
- compleLe arLs 1A, 1C, 1u, 3 and 6 of Lhls form,
- ask your doctor of choice to complete Part 6A, and
- uck Lhe klnd of card your parenL(s) has and wrlLe ln Lhe number below.
Medical Card GP Visit Card Card Number
If No and lf you are llvlng wlLh your parenL(s) or llvlng away from parenLal home for purposes of auendlng
school or college, your parenLs musL compleLe all parLs of Lhls form, llsung you as a dependanL aged 16-23.
1D - Auend|ng schoo| or th|rd |eve| co||ege?
Are you ln school or Lhlrd level educauon? ?es no
If 'es', whaL ls Lhe name of your school or college?
When wlll you nlsh your course?
Please ask your school or college to stamp this form.
School or college stamp:
art 2 - our dependants
our dependants aged under 16
I|rst name Surname Date of b|rth S number ke|anonsh|p
to you

D D M M Y Y Y Y
Medical Card and GP Visit Card Form MC1 5
MC1 Sept 2013
art 2 - our dependants - conunued
our dependants aged between 16 and 2S |n schoo| or co||ege or rece|v|ng an |ncome of
|ess than 164 per week
art 3 - Deta||s of |ncome
(|ease g|ve deta||s of a|| |ncome that you and your spouse or partner rece|ve each week)
I|rst name Surname Date of b|rth S number ke|anonsh|p kece|v|ng a
to you 3rd |eve|
educanon
grant?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
D
D
D
D
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Source Amount Irequency of
payment (for examp|e,
week|y, fortn|ght|y,
monthly or yearly)
1ype of
payment
Documents to send to us
(Photocopies only please)
Recent An Post receipt slip
or recenL bank sLaLemenL (lf
payment is paid direct to bank
accounL). lf ln recelpL of lllness
8eneL or MaLernlLy 8eneL,
a leuer from your employer
conrmlng your currenL wage,
lf any, ln addluon Lo Soclal
Welfare payment
Social Welfare E
payments
Most recent payslip Wages and or pension E
LaLesL nouce of AssessmenL
from 8evenue Commlssloners
Income from E
self employment
Conrmauon leuer from
awarding authority and
L121/S1 form
Social security payments E
from anoLher Lu sLaLe
Please put the name
of the LU state here:
8elevanL documenLary
evldence
Any other income E
(for example, malnLenance
payments, social security
paymenLs from non-Lu sLaLe)
A. our |ncome deta||s
Source Amount Irequency of
payment (for examp|e,
week|y, fortn|ght|y,
monthly or yearly)
1ype of
payment
Documents to send to us
(Photocopies only please)
Recent An Post receipt slip
or recenL bank sLaLemenL (lf
payment is paid direct to bank
accounL). lf ln recelpL of lllness
8eneL or MaLernlLy 8eneL,
a leuer from your employer
conrmlng your currenL wage,
lf any, ln addluon Lo Soclal
Welfare payment
Social Welfare E
payments
Most recent payslip Wages and or pension E
LaLesL nouce of AssessmenL
from 8evenue Commlssloners
Income from E
self employment
Conrmauon leuer from
awarding authority and
L121/S1 form
Social security payments E
from anoLher Lu sLaLe
Please put the name
of the LU state here:
8elevanL documenLary
evldence
Any other income E
(for example, malnLenance
payments, social security
paymenLs from non-Lu sLaLe)
6 Medical Card and GP Visit Card Form MC1
MC1 Sept 2013
art 3 - Deta||s of |ncome - conunued
8. our spouse's or partner's |ncome deta||s
(If you do not have a spouse or partner, p|ease go to secnon C on th|s page)
C. 8ack to emp|oyment or educanon scheme (for examp|e, Commun|ty Lmp|oyment Scheme)
(If you are not work|ng on or auend|ng such schemes, p|ease go to secnon D on next page)
|ease send us:
- a |euer(s) from the scheme superv|sor(s) show|ng the start date and expected hn|sh date for you
and or your spouse, and
- a copy of the most recent pays||p(s).
Scheme type Start date Lxpected hn|sh date
You
Scheme type Start date Lxpected hn|sh date
Spouse or
partner
D
D
D
D
D
D
D
D
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
art 3 - Deta||s of |ncome - conunued
D. Sav|ngs and |nvestments
If you don't have enough room to comp|ete th|s secnon, p|ease wr|te add|nona| deta||s on a separate sheet
of paper and send |t |n w|th th|s form.
If you don't have enough room to comp|ete th|s secnon, p|ease wr|te add|nona| deta||s on a separate sheet
of paper and send |t |n w|th th|s form.
Amount(s) invested
or held in savings E
Address Deta||s of |and or property
(for examp|e, 3 bed sem|, shop
un|t, farm|and or other)
ear|y |ncome rece|ved
(for examp|e, from renta|,
from lease or from other)
ear|y costs
1ype of sav|ngs or |nvestments Name and address of hnanc|a| |nsntunon
where invested or deposited
uo you or your spouse or parLner have lnvesLmenLs ln sLocks, shares or savlngs
wlLh banks or bulldlng socleues or oLher nanclal lnsuLuuons? ?es no

If No, go Lo arL L on Lhls page.
If 'es', please compleLe Lhe deLalls below and remember Lo auach phoLocoples of Lhe documenLs you need
Lo send us as evldence of your lncome from Lhese sources, for example, sLaLemenL(s) from nanclal
lnsuLuuon(s) showlng Lhe currenL balance on accounL(s).
L. roperty add|nona| to the fam||y home
Do you or your spouse or partner own any property or land other than the
house you llve ln, lncludlng land noL personally used? ?es no
If No, go to Part 4 on next page.
If 'es', please compleLe Lhe deLalls below and send us evldence of any lncome from Lhls source, for
example, Lenancy agreemenL or bank sLaLemenLs. Also, lf lL applles, please send us evldence of any cosLs
assoclaLed wlLh Lhe land or properLy, for example, recelpLs or lnvolces.
Medical Card and GP Visit Card Form MC1 7
MC1 Sept 2013
8 Medical Card and GP Visit Card Form MC1
MC1 Sept 2013
art 4 - Iam||y expenses
A. nous|ng
Payment
expense
Rent
Mortgage
Mortgage
proLecuon
House
insurance
Irequency (for examp|e, week|y,
month|y, year|y)
Documents to send to us
(Photocopies only please)
Up-to-date copy of tenancy
agreement or rent book
Recent mortgage account
statement or 3 months
recent bank statements
showing mortgage payments
8ecenL cerucauon from
provlder conrmlng paymenL
8ecenL cerucauon from
provlder conrmlng paymenL
Amount
E
P
P
P
8. Ch||dcare
Lxpenses on the fo||ow|ng ch||dcare arrangements are accepted: crche, montessor|, p|aygroup,
aher schoo| fac|||ty, ch||d m|nder, au pa|r and nanny
Week|y
amount
E
1ype of ch||dcare
(see examp|es above)
Name, address and te|ephone
number of ch||dcare fac|||ty
Documents to send to us
(Photocopies only please)
Leuer from
chlldcare provlder
conrmlng paymenL
E
E
Locanon of
employment
You
Spouse
or
partner
1ransport used
(for examp|e, car,
bus, tra|n)
If car, are you the
reglsLered owner?
Yes No
Copy of vehlcle
reglsLrauon cerucaLe
or Lravel uckeLs
Copy of vehlcle
reglsLrauon cerucaLe
or Lravel uckeLs
If car, are you the
reglsLered owner?
Yes No
D|stance you
travel in
k||ometres
each week
If pub||c or shared
transport, cost
each week
Documents to send to us
(Photocopies only please)
C. 1rave| to work costs
Medical Card and GP Visit Card Form MC1 9
MC1 Sept 2013
D. Ma|ntenance payments that you or your spouse or partner make to another person
Irequency of payment
(for examp|e, week|y, fortn|ght|y,
monthly or yearly)
Name and address of
the person who gets the payment
Amount
E
Copy of current
maintenance agreement or
leuer from person you make
paymenL Lo conrmlng
amounL belng recelved and
frequency of paymenL
Documents to send to us
(Photocopies only please)
art 4 - Iam||y expenses - conunued

I. Med|ca| expenses
Documents to send to us
(Photocopies only please)
Medlcal bllls or lnvolces
and or payment receipts
If you and or any of your dependanLs has ongolng medlcal expenses or expenses relaLed Lo a parucular lllness,
please glve deLalls of Lhe lllness and Lhe assoclaLed cosLs. lf you wanL us Lo Lake Lhese cosLs lnLo accounL, you
musL glve us evldence of Lhe cosLs (such as coples of bllls, lnvolces and or recelpLs). Lxamples of expenses
include doctors or consultants fees, hospital charges, cost of prescribed medicines or appliances or any other
such expenses.
Deta||s of |||ness Lxpense costs
Irequency of payment
(for examp|e, week|y, fortn|ght|y,
monthly or yearly)
Documents to send to us
(Photocopies only please)
Copy of mosL recenL lnvolce
or leuer from nurslng home
Amount
E
L. Net cost of pr|vate nurs|ng home care for you and or your spouse or partner
(that |s, the fu|| cost of nurs|ng home care |ess any amount the hea|th author|ty pays toward the cost)
Name and address of nursing home
If you don't have enough room to comp|ete th|s secnon, p|ease wr|te add|nona| deta||s on a separate sheet
of paper and send |t |n w|th th|s form.
10 Medical Card and GP Visit Card Form MC1
MC1 Sept 2013
art S - Dec|aranon and consent
8efore comp|enng th|s part of the form, please Lake ume Lo read and conslder Lhe followlng important
|nformanon:

8y law, anyone who dellberaLely glves false lnformauon on Lhls form, or who dellberaLely wlLhholds
lnformauon relevanL Lo an assessmenL of ellglblllLy for a Medlcal Card and C vlslL Card, could face a ne,
imprisonment or both.
Also, by law, anyone who does noL Lell Lhe PSL abouL a change ln Lhelr clrcumsLances LhaL could aecL Lhelr
ellglblllLy for a Medlcal Card or a C vlslL Card could face a ne.
Dec|aranon and consent
|ease read these statements. If you agree w|th them, p|ease comp|ete and s|gn or mark the form be|ow.
I apply for a Medical Card or a GP Visit Card for myself and, if it applies, my dependants.
l declare LhaL Lhe lnformauon l have glven as parL of Lhls appllcauon ls correcL Lo Lhe besL of my knowledge.
l agree Lo Lell Lhe PSL lmmedlaLely abouL any changes LhaL may aecL my own or, lf lL applles, my
dependanLs' ellglblllLy for healLh servlces.
l agree LhaL Lhe PSL, when assesslng ellglblllLy, may conLacL oLher CovernmenL ueparLmenLs lncludlng Lhe
ueparLmenL of Soclal roLecuon, Lhe 8evenue Commlssloners and Lhe ueparLmenL of !usuce Lo conrm Lhe
lnformauon l have glven.

Please sign here: Date:
D D M M Y Y Y Y


Place your mark here:
Signature of witness: Date:
Address of witness:
If you are not ab|e to s|gn, your mark shou|d be made and w|tnessed. 1he w|tness
shou|d s|gn h|s or her name and comp|ete h|s or her address |n spaces prov|ded be|ow.
D D M M Y Y Y Y





l agree Lo provlde medlcal servlces Lo Lhls appllcanL and hls or her dependanLs, lf any.
SlgnaLure of docLor: CMS S1AM PL8L:
GMS no.
Date:
D D M M Y Y Y Y
uocLor's name: uocLor's pracuce address:
Wlll your dependanLs (lf you have
Yes No
any) auend Lhls docLor?
uocLor's name: uocLor's pracuce address:
Wlll your dependanLs (lf you have
Yes No
any) auend Lhls docLor?
MC1 Sept 2013




art 6 - Doctor of cho|ce
art 6A - Doctor's acceptance
Ask your doctor to comp|ete th|s secnon of the form
art 7A - Doctor's acceptance (for spouse or partner)
Ask your spouse's or partner's doctor to comp|ete th|s secnon of the form
art 7 - Spouse's or partner's doctor of cho|ce
l agree Lo provlde medlcal servlces Lo Lhls appllcanL and hls or her dependanLs, lf any.
SlgnaLure of docLor: CMS S1AM PL8L:
GMS no.
Date:
If your spouse or partner requ|res a d|erent doctor of cho|ce, p|ease comp|ete art 7 and ask the|r
doctor to comp|ete art 7A.
Comp|ete Check||st on next page.
Medical Card and GP Visit Card Form MC1 11
D D M M Y Y Y Y
12 Medical Card and GP Visit Card Form MC1
Check||st
Pave you compleLed all relevanL parLs of Lhls form?
Pave you lncluded phoLocoples of evldence of all lncome and asseLs declared ln arL 3?
Pave you lncluded phoLocoples of evldence of all expenses declared ln arL 4?
Pave you lncluded phoLocoples of Lhe L or S form or a leuer from Lhe uk enslons 8oard, lf you are
applylng under Lu regulauons?
Pave you read and slgned or marked arL 3?
Has your doctor completed Part 6A and, if it applies, has your spouses or partners doctor
compleLed arL 7A?
lf you have any quesuons before you send o Lhls form, please phone Ca||save 1890 2S2 919 or
call to your Loca| nea|th Cmce.
Please send your completed form and copies of the documents we ask for, to:
C||ent keg|stranon Un|t
C 8ox 1174S
I|ng|as
Dub||n 11.
Data rotecnon and Ireedom of Informanon Nonce
1he PSL wlll LreaL all personal lnformauon and daLa you provlde as parL of Lhls appllcauon as
condenual and sLore lL securely. When Lhe PSL recelves your compleLed appllcauon form
and any supporung documenLs, lL wlll make a compuLer record ln your name. 1hls record wlll
conLaln Lhe relevanL personal lnformauon you have supplled. 1hls personal record wlll be
used and reLalned by Lhe PSL, solely for Lhe purposes of processlng your Medlcal Card and
C vlslL Card appllcauon.
1he PSL wlll noL dlsclose (share) Lo oLher people or organlsauons Lhe personal lnformauon
you have glven unless permlsslon has been glven by Lhe person Lo whom Lhe lnformauon
relaLes or Lhe PSL ls requlred Lo do so by law.