IRELAND DIRECTIVE POST

Refund application for planned, emergency or necessary medical treatment in private clinic abroad– DIRECTIVE ROUTE POST TREATMENT
Who is filling this application?*

This is my claim for a refundI am making an application on behalf of a patient under 18 years of age or over 18 years of age and dependant
INFORMATION ABOUT THE PATIENT
Name of the patient

First NameLast Name
Date of birth of the patient

MonthDayYear
Address
Telephone Number
Mobile Number
PPS Number
Email
Medical card number
Are you in receipt of a pension or other income from another country? If so which other country and please provide details to include the nature and value of the income.
Dose patient have private health insurance?*

YesNo

Information about PATIENTS private insurance
Name of the private health insurance company
Membership number
Has PATIENT applied to heath insurance company for funding?*
If yes, has funding been approved?
Please upload the decision from Insurance company, if you have a copy.

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Cancelof

GP's Detailes
Name of Patient's GP
GP's Address

0/50
GP’s Telephone Number

Parent/Guardian Details
Relationship to patient
Name
Address
Telephone number
Mobile number
Do you have private health insurance?

YesNo
Name of the private health insurance company
Membership number
Have you applied to heath insurance company for funding using your insurance?*
If yes, has funding been approved?

Type a question

I acknowledge that I will lose the right to cancel the order within the statutory period of 14 working days as we will commence the delivery of an order immediately and before this statutory period ends. Therefore the services will have deemed to have been provided and you will lose the right to cancel your order. The information that I give on this form is correct and complete to the best of my knowledge and I have read and accept the terms of the privacy policy.I confirm that the patient mention in this application does not have healthcare cover from another country besides the Republic of Ireland (such as having an S1, E121, E106, or E109).I confirm that patient lives in the Republic of Ireland.I hereby apply to assistance with my claim for reimbursement of medical expenses incurred whilst on a temporary stay in another member state for myself or my dependants. I declare that the information given by me on this form is to the best of my knowledge and belief correct. I agree to immediately report to the HSE any changes in my circumstances

My Products
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Treatment abroad Refund application IRELAND
€50.00

I want my case to be prioritised
€25.00

Total

€0.00
Should be Empty:

Refund application for planned, emergency or necessary medical treatment in private clinic abroad– DIRECTIVE ROUTE POST TREATMENT

INFORMATION ABOUT THE PATIENT

Information about PATIENTS private insurance

GP's Detailes

Information about treatment abroad