Get Medical Application Form

Filling out the Medical Application Form online can streamline the process of applying for medical benefits. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part 1, provide the applicant's details. Use block capitals for clarity. Fill in your surname, first name(s), date of birth, address, gender, daytime phone number, and PPS number. Indicate if you are ordinarily resident in Ireland and whether you live alone.
3. Also in Part 1, indicate your marital status by selecting the appropriate option and include details about your previous medical card, if applicable.
4. In Part 2, fill in the details of your spouse or partner, including their name, date of birth, gender, and PPS number.
5. Part 3 requests details of income. Indicate your weekly income and that of your spouse or partner from all sources, and attach evidence of this income. Include indications of any investments or properties owned.
6. Part 4 requires you to specify your doctor of choice, including their name and practice address, and the distance from your home to their center of practice.
7. In Part 5, read and sign the declaration and consent statement to confirm that you consent to the processing of your data and to verify that the information provided is accurate.
8. Finally, review the checklist at the end of the application to ensure all parts have been completed and required signatures are obtained. When everything is in order, submit the form.

Complete the Medical Application Form online to facilitate your healthcare needs.