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Application Form Medical card

Long-Term Illness (LTI) Scheme
Registration Form Domiciliary Care Allowance (DCA)

Free drugs, medicines, medical and surgical appliances for certain long-term illnesses.
Please read ‘Help and information’ on page 4 before completing this form.
Complete all applicable sections of this form. For official use only
Complete
Please all in
complete four parts letters,
CAPITAL of thisinform.
black FOR OFFICIAL
biro and place a tick (✓) where appropriate in Reference number:USE ONLY
Please complete in CAPITAL letters
the single boxes provided. Date Reference
received:number:
and place a tick (✓) where appropriate
Date received:
in the single boxes provided.
You can also apply for the Long-Term Illness Scheme on www.myLTI.ie

Part 1A Parent’s or guardian’s details (parent or guardian who is in receipt of a DCA payment)
You should only apply for the Long-Term Illness Scheme if you have been diagnosed with one or more of the
First Name: Surname: Date of birth: Gender: PPS number:
following longer term diseases or disabilities:
(Please tick)
Diabetes Mellitus Intellectual Disability
Acute Leukaemia Does not include Gestational Described in legislation as Mental
For example: Parkinsonism
For example:
Diabetes Handicap
0 5 1 1 1 9 7 0 2 2 2 1 1 1 1 A W
Mental Illness
Cerebral Palsy Epilepsy D D M M Under
Y Y 16Yyears.Y Does notM include F Phenylketonuria
Autism as a sole diagnosis

(parent or guardian who is in receipt of

Part
Cystic 1B
Fibrosis Parent’s Haemophilia
or guardian’s contact details
Multiple Sclerosis a DCA payment)
Spina Bifida

Address
Thalidomide
Diabetes Insipidus Hydrocephalus Muscular Dystrophies
Mobile Conditions
-

Please tick this box to accept SMS (text message)

There are two sections to this application form: from the HSE. You will receive updates on the
progress of your application.
Section 1: Should be completed by the applicant or by a parent or guardian signing for the
applicant. The applicant is the person who hastelephone:
Home been diagnosed with one of the 16
illnesses listed above.
Section 2: Should be completed by a doctor (for example, your GP or Hospital Consultant).
Email address:
Completed application forms should be returned to PCRS - PO Box 12962, Dublin 11,
D11 XKF3.
Part 1C Residency (where you live or intend to live)
Does your child (or children) live, or intend to live, in the Republic of Ireland for at least one year? Yes No

LTI December
MC-DCA: Page 2017
2021May 1 of 6
 Section 1A: Applicant’s personal details
First name(s): Surname:

Date of birth: D D M M Y Y Y Y Birth surname:

(If different)

PPS number: Gender: Male Female

Mobile phone:
Address:
(If you enter your mobile phone number, we may text you about
your application.)

Daytime phone:

Email address:

Eircode: E I R C O D E

Section 1B: Your residency status

To be eligible for the Long Term Illness Scheme, you must satisfy to the Health Service Executive (HSE)
that you are ‘ordinarily resident’. This means that you (and your family) are living in Ireland and intend to
live here for at least one year.
If it is the case that the person with the LTI (Long Term Illness) condition is a child under 18
years of age, you need to provide evidence of residency for the parent or legal guardian.

If you are not from the EU (European

Are you ordinarily resident? Yes No Union), the EEA (European Economic Area)
or Switzerland, what is your immigration
How long have you lived in Ireland?
status?
Are you?

Irish From the EU, EEA or Switzerland

Not from the EU, EEA or Switzerland

To prove that you are ordinarily resident in Ireland, you will need to give the HSE a photocopy of
one of the items listed below:

1. A current utility bill dated within the last three months, for example, a gas,
electricity or phone bill.
2. A current car or home insurance policy in the name of the applicant.
3. An official document from a Government Department, Revenue or local authority. For example a notice of
assessment from Revenue, proof of rent from the Housing Assistance Payment (HAP) or county council.
4. Recent correspondence from a bank, building society, credit union or other financial institution. For
example, a bank statement or credit card statement.

If you ticked the box saying that you were not from the EU, the EEA or Switzerland, you must also
give us a photocopy of all of the following three items.

1. The identification page from your passport.

2. The landing stamp page from your passport.

3. Your Irish Residence Permit (IRP).

LTI December 2021 Page 2 of 6

 Section 1C: Nominated pharmacy
Name:
Address:

(Please note this is optional.)

If you wish, you can give us the name of the pharmacy you use. This will allow us to get in touch with them if there is any
drug-related information we need to share. If you would rather not name a pharmacy, just leave this area blank.

Section 1D: Your GP’s details

Name:
Address:

Section 1E: Declaration and Consent – This section must be completed for processing.
I am applying for eligibility under the Long-Term Illness Scheme.

I declare that the information I have given is correct to the best of my knowledge.

I agree that the Primary Care Reimbursement Service (PCRS) may contact my nominated pharmacy to
confirm pharmaceutical information (information about medicines) on my application.

I agree that my pharmacist may contact the HSE to confirm that the prescribed medicines are approved
under the scheme.

I agree that the PCRS Medical Officer may contact my GP or hospital consultant to confirm medical
information on my application.

If it applies, I confirm that I am the parent or legal guardian of the named applicant, and I give consent
on their behalf.

Sign
Here
Signature:
✗ Date: D D M M Y Y Y Y

Section 1E: Declaration and Consent

You only need to fill in the two lines below if you are signing on behalf of the person making the
claim for Long-Term Illness

Your name:
Relationship to applicant:

LTI December 2021 Page 3 of 6

 Section 2 – Certification by general practitioner or hospital consultant
Please ask your GP or hospital consultant to fill out this section of the form
I certify that Name:
has one or more of the prescribed diseases or disabilities of a permanent or long-term nature covered by Section (3)
of the Health Act 1970 (as amended) that are listed on page 1.

Patient PPS Number: Patient Date of Birth: D D M M Y Y Y Y

Diagnosis: Please name all of the prescribed illnesses under the Long-Term Illness Scheme that apply, as that will
influence what drugs, medicines and medical or surgical appliances that will be provided free to the eligible person.

The following drugs, medicines, consumable medical and surgical appliances are needed to treat the prescribed
disease(s) or disability:

Drug or medicine, including its strength or pharmaceutical form (for example tablet, cream, solution
for injection) or a description of a medical or surgical appliance applied for*.

1. 11.

2. 12.

3. 13.

4. 14.

5. 15.

6. 16.

7. 17.

8. 18.

9. 19.

10. 20.
Doctor’s Stamp
Signature:

GP or Hospital Consultant

Name:

Medical
Council No. Date: D D M M Y Y Y Y
*You should arrange to get your surgical appliances and equipment through your local community
health organisation office.
LTI December 2021 Page 4 of 6
Data Protection and Freedom of Information Notice
The HSE will treat all personal information and data you provide as part of this application as confidential and
store it securely.

When the HSE receives the completed application form, we will make a computer record for the applicant
named on the form. This record will include the relevant personal information you have supplied.

We will keep this personal record and will only use it to process your Long-Term Illness application.

The HSE will keep your information private. We will not disclose (share) any of it with any other people or
organisations unless the person authorised to give consent agrees to our doing so or we are required to do
so by law.

Our Privacy Notice explains how we use your information you give us as part of your application form. You
can find this notice on www.medicalcard.ie or by calling Lo Call 0818 224 478.

Checklist of the documents you need to send with this form

To avoid a delay in our processing your application, please make sure you send us the following:
Completed and signed application form.

Copies of any relevant prescriptions.

If you applying under Attention Deficit Hyperactivity Disorder (ADHD),

please include a certification of assessment and diagnosis of ADHD,
provided by a specialist in childhood behavioural disorders.

Documentation to prove ‘Ordinarily resident’ – you must give us one item

from 1- 4 below.

1. A current utility bill dated within the last three months, for example, a bill for:
• gas
• electricity
• phone
2. A current car or home insurance policy in the name of the applicant.
3. An official document issued from a Government Department, Revenue or local authority.
For example:
a notice of assessment from the Revenue
proof of rent from the Housing Assistance Payment or county council.
4. Recent correspondence from a bank, building society, credit union or other financial institution.
For example:
• a bank statement
• credit card statement

If you ticked the box in Section 1A to say you are not from the EU, the EEA or Switzerland, you
must provide all of the following three items:

The identification page from your passport

The landing stamp page from your passport.

Your Irish Residence Permit (IRP).

LTI December 2021 Page 5 of 6

Submitting your form
If you have any questions before your send off this form, please LoCall 0818 224 478.

Please send your completed form to:

Long-Term Illness Scheme
Client Registration Unit
PO Box 12962
Dublin 11
D11 XKF3

LTI December 2021 Page 6 of 6