EHIC Application Form for Irish Pensioners and Insured Persons
This document is the EHIC application form for Irish pensioners and insured persons residing in other EU/EEA member states. It needs to be completed to apply for the EHIC from Ireland. Follow the instructions carefully to ensure successful submission.
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How do I fill this out?
To fill out the EHIC Application Form, ensure you have all the required information on hand. Provide accurate personal and contact details, and sign the form. Submit the completed form as per the given instructions.
How to fill out the EHIC Application Form for Irish Pensioners and Insured Persons?
1
Provide your personal information including name, address, and date of birth.
2
Enter your PPSN and current country of residence.
3
Fill in the details of your last address in Ireland, contact number, and email.
4
Indicate your source of income and pension reference number.
5
Sign the form and submit it to the provided address.
Who needs the EHIC Application Form for Irish Pensioners and Insured Persons?
1
Irish pensioners residing in other EU/EEA member states need this form to apply for an EHIC.
2
Insured persons residing in other EU/EEA member states need this form for health coverage.
3
Individuals planning to travel within the EU/EEA need this form for obtaining the EHIC.
4
Dependents of Irish pensioners need this form to be linked to health coverage from Ireland.
5
Individuals returning to their EU/EEA country of residence need this form as proof of coverage.
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3
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4
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What are the instructions for submitting this form?
Submit the completed EHIC Application Form to the EU Regulations Office, Health Service Executive, North West Wing, St. Joseph's Hospital, Mulgrave Street, Limerick, Ireland. Ensure all fields are accurately filled out and the form is signed. Use PrintFriendly to fill, sign, and share your form easily.
What are the important dates for this form in 2024 and 2025?
Ensure to submit your EHIC Application Form before your planned travel dates for timely processing. Pay attention to holidays and weekends that might affect processing times.
What is the purpose of this form?
The EHIC Application Form for Irish pensioners and insured persons residing in other EU/EEA member states is designed to provide essential health coverage while living abroad. By filling out this form, applicants can obtain the European Health Insurance Card (EHIC) from Ireland. This card ensures access to necessary medical services in other EU/EEA countries under the same conditions as residents of those countries.
Tell me about this form and its components and fields line-by-line.
- 1. Applicants Name: Enter the full name of the applicant.
- 2. Current Address in other EU/EEA member state: Provide the current residence address in another EU/EEA member state.
- 3. Date Of Birth: Enter the applicant's date of birth in the format (dd/mm/yyyy).
- 4. PPSN: Provide the Personal Public Service Number.
- 5. Current Country of Residence: Indicate the country where the applicant currently resides.
- 6. Last Address in Ireland: Provide the last address where the applicant lived in Ireland.
- 7. Telephone / Mobile No.: Provide a contact number.
- 8. Email Address: Enter a valid email address.
- 9. First Names: Enter the first name(s) of the applicant.
- 10. Surname: Enter the surname of the applicant.
- 11. Gender: Select the gender of the applicant (M/F).
- 12. Source of Income: Indicate the source of income.
- 13. Pension Reference No.: Provide the pension reference number.
- 14. Date E121 / E109 was registered: Enter the date when E121 / E109 was registered (dd/mm/yyyy).
- 15. Signature: Applicant must sign the form.
- 16. Date: Enter the date of application.
What happens if I fail to submit this form?
Failing to submit the EHIC Application Form will result in not receiving the European Health Insurance Card. This can lead to lack of coverage in medical situations.
- No Health Coverage: You may not be covered for medical expenses in other EU/EEA member states.
- Delayed Treatment: Without the card, you may face delays in receiving medical treatments.
- Additional Expenses: You might incur extra costs for medical services without EHIC coverage.
How do I know when to use this form?
- 1. Apply for EHIC: To obtain the European Health Insurance Card from Ireland.
- 2. Update Information: To update personal or contact information for health coverage.
- 3. Renew Coverage: To renew health coverage while residing in another state.
- 4. Include Dependents: To include dependents under your health coverage.
- 5. Proof of Coverage: To provide proof of health coverage in your country of residence.
Frequently Asked Question
How do I fill out the EHIC Application Form?
Enter your personal information in the text fields, sign the form using the signature tool, and submit as per instructions.
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How do I know if my form is correctly filled?
Review all entries carefully before downloading or sharing to ensure accuracy.
What happens if I forget to sign the form?
The form will be incomplete without a signature, so be sure to sign using the signature tool.
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Where do I submit the completed form?
Submit the form to the EU Regulations Office, Health Service Executive, North West Wing, St. Joseph's Hospital, Mulgrave Street, Limerick, Ireland.
Related Documents - EHIC Application Form
European Health Insurance Card Application
This file provides instructions and an application form for obtaining a European Health Insurance Card (EHIC) in Ireland. It includes various methods to apply, required documents, and contact information for EHIC offices.
