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 refund
I 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 Name
Last Name
Date of birth of the patient
/
Month
/
Day
Year
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?
*
Yes
No
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Information about PATIENTS private insurance
Name of the private health insurance company
Membership number
Has PATIENT applied to heath insurance company for funding?
*
Please Select
Yes
No
If yes, has funding been approved?
Please upload the decision from Insurance company, if you have a copy.
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GP's Detailes
Name of Patient's GP
GP's Address
0/50
GP’s Telephone Number
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Information about treatment abroad
Country of treatment
Name of the Clinic/ Hospital
Name of doctor
Hospital/ Clinic address
Hospital/ Clinic email address
Type of treatment received
Consultation
Tests
Scans
One day surgery
Hospital stay overnight
Physiotherapy
Please specify treatment received
Outpatient/Consultation/ Scans / Tests / Inpatient
Outpatient consultation date
-
Day
-
Month
Year
Consultation has to take place prior or on the day of treatment
Type of outpatient consultation?
In person
Telephone
Video
Date of one day surgery
-
Day
-
Month
Year
Inpatient hospital admission date
-
Day
-
Month
Year
Inpatient hospital discharge date
-
Day
-
Month
Year
Specific treatment or procedure received
Surgery, MRI, Scans, Tests etc.
Summary of condition, complains
Use information provided on medical report
Specific treatment/s received
Use information in medical report
Upload medical report for your treatment abroad
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Are you receiving treatment in Ireland for your medical condition?
No
Yes
Provide details of treatment received in Ireland?
Why you decided to receive treatment abroad
Waiting times
Quality of service
Proximity to my place of residence
Other
Case number
Upload invoices/receipts for your treatment
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Parent/Guardian Details
Relationship to patient
Name
Address
Telephone number
Mobile number
Do you have private health insurance?
Yes
No
Name of the private health insurance company
Membership number
Have you applied to heath insurance company for funding using your insurance?
*
Please Select
Yes
No
If yes, has funding been approved?
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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
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This service is now offered on donation bases.
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