European Health Insurance Card - Application Form
Please send the completed form to your local Health Office
Address of Applicant / Family Telephone Number:
Mobile Number:
Departure Date:
Signature:
Return Date:
Date Received by Health Office:
New Application: Renewal:
Date:
Data Protection Notice:
The information on this form will be transmitted to the HSE-PCRS so that an EHIC card(s) may be issued to the person(s) named thereon.
I hereby apply for European Health Insurance Card(s) I declare that the persons listed are ordinarily resident in the Republic of Ireland
PPS Number
Gender Date of Birth
First Name (s) Surname (M/F) (dd/mm/yyyy)
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