Feidhmeannacht na Seirbhse Slinte

Bosca Poist 11862

Baile tha Cliath 11

Health Service Executive

PO Box 11862
Dublin 11

Guthn: (1890) 25 2919

Tel: (1890) 25 2919

Private & Confidential

MARIUS CRISTIAN NISTOR
Hawthorn Cottage
Killakee Road
Dublin
Dublin 16

24 SEP 2015

Re : Your Medical Card Review - Reference Number 5361176

Dear Mr. Nistor,
Your Medical Card Review was completed online on 24/09/2015. To finalise the process and enable
the HSE to issue your Medical Card please follow these steps carefully.
Step 1 : Read your review form carefully to confirm that all the details are correct. Only correct
review forms can be processed. If your review form is not correct it will be returned
to you for correction and resubmission.
Step 2 : You need only complete this section if you wish to change your existing Doctor of Choice.
Step 3 : Read, sign and date the declaration and consent.
Step 4 : Enclose any evidence required and return together with the review form to
Client Registration Unit,
PO Box 11862,
Dublin 11.
If you need any assistance or advice please contact us on Lo-call 1890 25 2919 and quote your
reference number 5361176. We are anxious to process your review as quickly as possible and in order
to do so request that you return this pack, as soon as possible please.
Yours Sincerely,

Siobhn McArdle,
National Medical Card Unit

Help Us to Help You:

The main problem experienced with review forms received is that all of the required documentary evidence of income and
outgoings is not submitted.
The last page of this pack gives details of the types of evidence required.
Unfortunately if all evidence is not provided the review cannot be processed and will be returned to the sender.
If you do not submit your complete review pack to us within two weeks your review will be removed from the system. If you
wish to apply again after that time you will need to start the review process again.

Medical Card Review - Reference Number 5361176

Step 1 : Read Your Medical Card Review.

*OP-5361176*

Section A : Applicant Details

Surname

NISTOR

Irish Resident

Yes

Forename

MARIUS CRISTIAN

Address

Hawthorn Cottage

Date of
Birth

12 AUG 1982

Phone

353872751784

Town

Dublin

Gender

Male

County

Dublin 16

PPSN

2336410L

Birth Surname

Email

zispiss@yahoo.com

Mother Surname

Do You Live Alone?

Killakee Road

No

Marital Status

Married

If 'No' who do you live with? wife

Medical Card

A347725

Doctor Name

DR. JAMES LEE

MC

Card Issued From

Not supplied

Section B : Details of Your Spouse / Partner

Surname

NISTOR

Birth Surname

Forename

CAMELIA

Mother Surname

Date of
Birth

07 JAN 1982

Gender

Female

PPSN

1785074U

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ONET

Medical Card Review - Reference Number 5361176

Section C - Details of Dependants

No Dependents Supplied

Page

2 of 6

Medical Card Review - Reference Number 5361176

Section D - Details of Income for Applicant

Jobseekers Allowance/Benefit
Rental Income whether arising in the State or otherwise.

188.00
0.00

Savings and Investments amount

0.00

Section E - Details of Income for Spouse / Partner

Maternity Benefit
Rental Income whether arising in the State or otherwise.

250.00
0.00

Savings and Investments amount

0.00

Section F - Details of Outgoings for Applicant

Reasonable expenses incurred in travel to work
Expenses incurred in respect of rent

0.00
200.00

Section G - Details of Outgoings for Spouse / Partner

Reasonable expenses incurred in travel to work

0.00

Page

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Medical Card Review - Reference Number 5361176

*OP-5361176*

Step 2 - Doctor of Choice

A Family Doctor or GP must sign this section, agreeing to provide medical services to you and your
dependants. Contact your selected GP's surgery and ask the doctor to sign your Review form. A list of
GPs is available on www.hse.ie or your Local Health Office. You need only complete this section if you
wish to change your existing Doctor of Choice.
Doctors Practice Address

Applicant, MARIUS CRISTIAN NISTOR

Miles from your home to Doctor's
main centre of practice
Dependants will attend this doctor?

Yes

No
Doctors Stamp

Doctors Signature

Doctors GMS Number

Doctors Practice Address

Spouse/Partner, CAMELIA NISTOR

Miles from your home to Doctor's
main centre of practice
Dependants will attend this doctor?

Yes

No
Doctors Stamp

Doctors Signature

Doctors GMS Number

Page

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Medical Card Review - Reference Number 5361176

*OP-5361176*

Step 3: Read, Sign and Date the Declaration and Consent

(a) To process your application, the HSE may seek access to Revenue and Social Welfare data to confirm details
of you and your dependants, if any. The HSE may also seek access to Revenue and Social Welfare financial
details relevant to this application and further reviews. Your signature below shows that you consent to this
access.
(b) A person who knowingly makes a false statement, fails to disclose any material fact or produces a false
document as part of this application is liable to a fine and/or to imprisonment under Section 75 of the Health Act
1970 as amended by the Health (Amendment) Act 2005.
(c) A person who fails to notify the Health Service Executive of a change in circumstances which would affect
their eligibility for a Medical Card / GP Visit Card is liable to a fine under Section 49 of the Health Act 1970 as
amended by the Health (Amendment) Act 2005.
I hereby apply for a Medical Card / GP Visit Card for myself and my dependants as listed. I have read the above
notes and 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 which may affect my eligibility for health services
and that of my dependants.

Date

Signature

MARIUS CRISTIAN NISTOR

Data Protection Notice

Personal data collected by the HSE PCRS is used for the purpose of providing a health service. It is required,
stored, processed and disclosed to other bodies in accordance with the laws relating to proper treatment of
personal data.

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Step 4: Enclose Evidence Required and Return with the Review

To support your application, you must provide the HSE with documentary evidence of the information you provide
on:

PPS Number (e.g. tax cert, P60, P45, payslip, social welfare book)
Total Household Income (e.g. payslip, social welfare book, notice of tax assessment)
Outgoings (e.g. rent book, mortgage or bank statement, maintenance payments, travel to
work costs (include proof of car ownership, if appropriate), receipts for childcare costs)
Commencement and expected completion dates of 'Back to Employment / Education'
Schemes
If you are claiming under E.U. Regulations, please enclose the relevant E Form from the
other European State.
Travel to work costs (e.g. copy of Vehicle Registration Certificate if claiming travel to work
costs by car)

Address for the Submission of Your Completed Review

Client Registration Unit,
PO Box 11862,
Dublin 11.

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