Illness Benefit Certification
Name
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First Name
Last Name
Date Of Birth
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-
Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
PPS Number(A Certificate cannot be completed without the correct number)*
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Which type of certificate? MED 1 = applies to most illnesses MED 2 = only choose if you have a letter from a government department instructing you to apply MED2 instead of MED1)*
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Med 1
Med 2-4 weeks
Med 2-13 weeks
Med 2-26 weeks
Dates Certificate applied for (Note: Certificate duration is a function of the claimant's illness,the Departments guidelines for expected length of absence and the GP's clinical judgement. Above dates are indicative. They are not the definitive dates.)*
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llness causing absence(Short Description)*
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Consent for E-Certificate (I consent to the electronic transmission of my data by the GP to the department of Employment and Social Protection)*
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I Agree
Correct form chosen? Wrong from affects payment (Please check you have chosen the correct MED 1 or MED 2 option. Read the conditions for choosing MED 2 and change if wrong type chosen.)*
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I have chosen the correct type
My Products
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