Forms
Below is a selection of the most commonly used medical application forms and other helpful links for your information. To get the form you want, just click on it from the list below and you'll be able to download it straight to your computer.
GP Visit Card Under 6 Application
Children under the age of 6 are entitled to free visits to participating GPs, including Annagh Medical Centre. The card also allows for free visits to the GP for children up to the age of 6 and also covers specific assessment at ages 2 and 5. Care for children with asthma is also covered.
If you would like to apply for a GP Visit Card Under 6, you can download the application form from the button below.
Medical Card/ GP Visit Card – Over 70 Application Form (MC1(a))
Administered by the HSE, those over 70 can apply for a medical card or a GP visit card, depending on their circumstances. This medical card is available to anyone aged 70 or over who has a gross income of not more than €500 a week for a single person or not more than €900 per week for a couple. The application form for the Over 70 Medical Card/ GP Visit Card can be downloaded here, with details included on how you can submit your application to the HSE.
Disability Allowance Application Form (DA1)
Disability Allowance is a weekly allowance paid to people with a disability.
To qualify for Disability Allowance, applicants must meet the following criteria:
- They must have an injury, disease or physical or mental disability that has continued, or may be expected to continue, for at least one year.
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- As a result of this disability, the applicant must be substantially restricted in
undertaking work that would otherwise be suitable for a person of your age,
experience and qualifications.
- The applicant must be aged between 16 and 66. Those who reach 66 years of age no longer qualify for Disability Allowance but are assessed for a State pension.
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Disability Allowance is administered by the Department of Employment Affairs and Social Protection. To apply you can download the Disability Allowance application form from the Annagh Medical Centre website and submit your application as outlined on the form.
Domiciliary Care Allowance Application Form
The Domiciliary Care Allowance is a payment made to people on low incomes who are looking after a person in need of support due to age, disability or illness (including mental illness). Those who qualify for the Carers Allowance may also quality for free household benefits (if they are living with the person who is being cared for) and a Free Travel Pass. The application form for the Domiciliary Care Allowance can be downloaded from the Annagh Medical Centre website. The scheme is administered and processed by the Department of Employment Affairs and Social Protection.
Invalidity Pension Application Form (INV1)
The Invalidity Pension provides a weekly payment to people who are unable to work due to a disability or long-term illness, so long as they are covered by their PRSI. The payment only applies to people below pension age as at the age of 66 anyone qualifying for the Invalidity Pension is transferred to the regular State Pension.
Those who wish to apply for the Invalidity Pension can download the application form from the Annagh Medical Centre website. The scheme is administered by Social Welfare Services so all completed forms should be submitted to the address listed at the end of the form.
Maternity Benefit Application Form (MB10)
Maternity Benefit is a payment provided to women who are on maternity leave from work, so long as they are covered by their PRSI. Anyone who is looking to receive the maternity benefit is advised to submit their application at least 6 weeks before they go on maternity
leave (and at least 12 weeks if the person is self-employed).
The application form for Maternity Benefit can be downloaded from the Annagh Medical Centre website. The benefit is administered by the Department of Social Protection and completed forms should be submitted to the address provided on the Maternity Benefit
Application Form.
Driving Licence Medical Report Form
Under Irish and EU law, certain people must include a Driving Licence Medical Report when they are submitting their driving licence application. In particular this form is required when for anyone who is:
- Applying for a learner permit or driving licence in any of the following categories –
C1, C, D1, D, CE1, CE, DE1 or DE.
- Will be 70 years of age or more on the first day for which the licence or Learner
Permit is being granted.
- Suffers from certain disabilities or diseases. This includes conditions like diabetes,
strokes, fit or blackouts, anyone with a cardiac pacemaker or implanted defibrillator,
multiple sclerosis, motor neurone disease, Parkinson disease, Huntington’s disease,
sleep apnoea syndrome, narcolepsy, repeated dizziness attacks, any kind of brain
surgery, alcohol or drug dependency or a range of other conditions. Have ever suffered from epilepsy or alcoholism.
- Are taking drugs or medication on a regular basis which would be likely to make a
person an unsafe driver.
The Driving Licence Medical Report must be completed by a registered medical practitioner and the applicant must sign the form in their presence. At Annagh Medical Centre we have extensive experience of completing these Driving Licence Medical Report forms and can go through the details with any of our patients who may require additional information.
Eyesight Medical Report Form
Under Irish and EU law, certain people must include a Driving Licence Eyesight Report when they are submitting their driving licence application. In particular this form is required when for anyone who is:
- Where you previously wore glasses/lenses and are no longer required to do so.
- It is also needed in certain cases when exchanging a licence from another country outside of the EU.
Once completed the person applying must submit their application to the National Driver Licence Service within one month of it being signed by the medical practitioner.
European Health Insurance Card Application Form (EHIC)
The European Health Insurance Card is used by people who are from an EU/ EEA country and are travelling or staying temporarily in another EEA state (or Switzerland). It makes it easier to get medical care quickly and simply in these other countries as it provides evidence that you are part of a health insurance scheme administered by another EU/ EEA state. Completed forms are submitted to the applicant’s local health office.
Drugs Payment Scheme Application Form
The Drugs Payment Scheme is a Government programme to assist families and individuals with their medical costs. Under the Drugs Payment Scheme, no individual or a family will have to pay more than the approved monthly threshold for their prescribed drugs, medications and appliances in a calendar month. From January 2019 that threshold will be €124 per month. Completed forms are submitted to the local health office. To find out more information about your local health office click here.
