4 Declaration

I declare that the information I have given on this application is correct and complete and I understand that if not, this could delay my application and that appropriate action may be taken. I shall inform the NHS Business Services Authority (NHSBSA) if any of the information provided on this application is subject to change. I confirm that all persons named on this application are ordinarily resident in the UK. I understand that should my dependants or I remain abroad, to live or work, then the relevant authorities must be informed. I understand that this card is not an entitlement card for NHS services, or proof of identity. I am the main applicant I am a representative for the main applicant Relationship to applicant

Application form for

European Health Insurance Card (EHIC) The quickest way to apply for a card is online at www.dh.gov.uk/travellers
or by calling the EHIC Application Line on 0845 606 2030.

How to complete this form

To help us to process your application quickly, please write clearly in BLOCK CAPITALS inside the boxes using black ink only.

Notes 1 Please give:

NHS number (England and Wales) Community Health Index number (Scotland) Health and Care number (Northern Ireland) Alternatively, you can give your National Insurance number. For dependent children: if you do not know these numbers, please give the applicants NHS or National Insurance number.

S U R N A M E
Signature Date

D D / MM / Y Y Y Y

You must complete all the questions asked for each applicant or family member. For more detailed information, please visit www.dh.gov.uk/travellers

Data protection Act 1998 The NHS Business Services Authority (NHSBSA) and Department of Health acting as joint
Data Controllers, will only use the information provided on this form for processing your application for the European Health Insurance Card (EHIC). Your details, in relation to this application, will be removed from our files no later than 24 months after the expiry of your EHIC. We will not transfer your Personal Data outside of the European Economic Area or disclose it to any third party other than the Department for Work and Pensions (for the purpose of validating EHIC claims) and the NHS Counter Fraud and Security Management Service and Department of Health International Division (in order to prevent and detect fraud and errors). We may contact you to discuss your application by any of the methods you have provided on the application.

2 If you do not have British, other

EU/EEA or Swiss nationality, please visit www.dh.gov.uk/travellers or phone the EHIC Enquiries Line on 0845 605 0707.

EHICS0509

Office use only

Evidence unacceptable Storage reference Checker initials

E106/Evidence expiry date D D / M M / Y Y Y Y

EHICS0509

1 The applicant
Personal details
Title Surname Forenames Date of birth must be over 16 years old NHS number see note 1 Do you have British, other EU/EEA or Swiss nationality? Are you planning to reside permanently outside the UK? Posted workers should answer No If yes, what date do you expect to leave the UK? Yes Yes No see note 2 No Mr Mrs Ms Miss Other

3 Dependent children
Dependent child 1 up to the age of 16 (or 19 if they are in full-time education).
Title Surname Forenames Mr Miss

D D / MM / Y Y Y Y

Date of birth NHS number see note 1

D D / MM / Y Y Y Y

Dependent child 2 up to the age of 16 (or 19 if they are in full-time education).

Title Surname Forenames Date of birth NHS number see note 1 Mr Miss

D D / MM / Y Y Y Y

U K EHIC Personal Identification Number Only for replacement or renewal of EHIC the number is shown on your existing EHIC
Contact information
House number (and/or house name) Street Town County Postcode Contact phone number (inc area code) Country

D D / MM / Y Y Y Y

Dependent child 3 up to the age of 16 (or 19 if they are in full-time education).

Title Surname Forenames Date of birth NHS number see note 1 Mr Miss

D D / MM / Y Y Y Y

2 Spouse/partner
Title Mr Mrs Ms Miss Other

Dependent child 4 up to the age of 16 (or 19 if they are in full-time education).

Title Mr Miss

EHICS0509

Surname Forenames Date of birth NHS number see note 1

Forenames

D D / MM / Y Y Y Y

Date of birth NHS number see note 1

D D / MM / Y Y Y Y

EHICS0509

Surname