[PDF] Overseas Healthcare Services European Health Insurance Card PDF ehic-application-form-february-2020.pdf

Further details are available at www nhsbsa nhs uk/yourinformation European Health Insurance Card (EHIC) application form How we use your information 1

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Overseas Healthcare Services

1/6How to complete this form

The quickest way to apply for a card is online at www.nhs.uk/ehic or by calling 0300 330 1350 from the UK or +44 191 279 0575 from abroad. Lines are open Monday to Friday 8am to 6pm, and Saturday 9am to 3pm (UK time). As the main applicant, you can also apply on behalf of your partner and/ or any dependent children. For each applicant or family member you are applying for, you must complete all the questions asked. For more detailed information visit www.nhs.uk/healthcareabroad. Post your completed application to: NHS Business Services Authority, EHIC, Bridge House, 152 Pilgrim

Street, Newcastle upon Tyne, NE1 6SN.

EHICS 0220The NHS Business Services Authority (NHSBSA) and the Department of Hea

lth and Social Care are jointly responsible for this service. We will use the information that you have given us to process and verify your applications and to make payments to and recover treatment costs from countries within the EEA, Switzerland and Gibraltar. We may share your information with the Department for Work and Pensions, HM Revenue and Customs, NHS England, Scotland, Wales and Northern Ireland and Gibraltar Health Authority (to validate your information), NHS Cou

nter Fraud Authority and international healthcare providers and administrators (to prevent, detect and investigate fraud and error). We may share patterns and trends gained from patient information with NHS commissioners, service providers and NHS England, Scotland, Wales and Northern Ireland (to plan and improve NHS services). We will not transfer your Personal Data outside of the UK, EEA, Switzerla

nd or Gibraltar. Data will be deleted from our systems and files no later than 48 months after the expiry date

of your EHIC. Further details are available at www.nhsbsa.nhs.uk/yourinformation. European Health Insurance Card (EHIC) application form

How we use your information

1. Declaration

- Read before signing

I understand that should the main applicant have a change to residency status, move abroad to live, or

work on a long-term basis, then he or she may no longer be entitled to a

UK EHIC. In these

circumstances NHSBSA must be informed and, if required, all associated EHICs returned.

I understand that if I have used the EHIC to access healthcare abroad when I am not entitled to do so, I

may be liable for the full cost of the treatment. I also understand that this also applies to EHICs for other

people named on this application.

I understand that the EHIC does not prove entitlement to NHS services, and does not prove entitlement

to planned treatment outside the UK. I also understand that this card is not a proof of identity or residency in the UK and is not an alternative to travel insurance. I have read and understood the eligibility requirements for receiving an EHIC in the 'Important information' section (page 6 of this application form). I confirm that I will give complete and accurate

information in relation to this application. I understand and accept that if I provide NHSBSA with false or

misleading information I may be liable for criminal prosecution. 2/6

EHICS 0220

1. Declaration (cont.)

- Read before signing I understand that the administration of the EHIC is the responsibility of the NHSBSA. I will supply any additional information which might be reasonably required by NHSBSA to verify information I have given on this form. I understand that the information on this form and otherwise in connecti on with this application may be shared with:

NHS Counter Fraud Authority

International healthcare providers and administrators you are treated by Department of Health and Social Care - International Division and Anti-Fraud Unit

Local Authorities

Credit reference agencies

Bodies performing functions on behalf of the above organisations

Law enforcement organisations, as required by law

for the purposes of the prevention, detection and investigation of fraud and error. The information can

also be used for the purposes of prosecution of fraud or any other unlawful activity affecting the NHS.

I understand the information on this form may be shared with:

The Department for Work and Pensions

HM Revenue and Customs

NHS England, Scotland, Wales, Northern Ireland and Gibraltar Health Authority for the purposes of verication. I understand to support more effective planning and improvements to NHS services and patient care, patterns and trends gained from patient information may be shared with:

NHS Commissioners and service providers

NHS England, Scotland, Wales and Northern Ireland

Department of Health and Social Care

NHS Counter Fraud Authority

We may contact you to discuss your application by any of the methods you have provided on the application.

I conrm that:

The main applicant specied in this application has British, EU, EEA or Swiss nationality. The main applicant specied in this application is ordinarily resident in the UK, and aged 16 or over. The persons named in this application have consented to their personal d etails being disclosed. I have read the Privacy Notice at www.nhsbsa.nhs.uk/overseas-healthcare-privacy

I am the main applicant

I am a representative for the main applicant

Full name of representative Relationship to main applicant

Permanent address of representative

If you are an organisation processing EHIC

applications on behalf of a customer, you must state your full business name and address, as well as Companies House registration or charity number (if applicable).

If you fail to provide this information the

application will not be processed.

Signature Date

3/6

EHICS 0220

Current permanent address

House number (and/or house name):

Street:

Town:

County:

Postcode:Country:

Contact phone number (inc. area code):

Passport number:

How long have you lived in the UK?Number of years

and months Do you have any plans to study abroad or move abroad permanently within the next ve years?

Posted workers should answer 'No'

Yes No

If 'Yes', what date do you expect to leave the UK?

EHIC Personal Identification Number (PIN): U K

Only for replacement or renewal EHIC - the number is shown on your exist ing EHIC

2. The main applicant

Title:Mr Mrs MsMiss Other

Surname:

Forename(s):

Date of birth (must be aged 16 or over):

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Name of your Local Authority, nd yours at www.gov.uk/nd-local-council

Nationality (if you are

not a UK, EU/EEA or Swiss national, send a copy of your visa or residence permit): 4/6

4. Dependent children

If you do not know their NHS number, give the main applicant's.

Dependent child 1

- under 16 years old

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Nationality:

Does this person live with the main applicant at the address given at section 2? Yes NoIf 'No', please send evidence with this application that they ar e dependent on the main applicant (e.g. an S1 form).

Dependent child 2

- under 16 years old

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Nationality:

EHICS 0220

3. Spouse/partner/civil partner

Title:Mr Mrs MsMiss Other

Surname:

Forename(s):

Date of birth:

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Nationality:

Does this person live with the main applicant at the address given at section 2? Yes NoIf No", send evidence with this application that they ar e dependent on the main applicant (e.g. an S1 form). 5/6

EHICS 0220

4. Dependent children (cont.)

If you do not know their NHS number, give the main applicant's.

Dependent child 4

- under 16 years old

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Nationality:

Dependent child 3

- under 16 years old

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

NHS number (England and Wales), Community Health Index number (Scotland) or Health and Care number (Northern Ireland):

Nationality:

Important information

A valid EHIC provides card holders with the right to access state-provided healthcare on temporary stays

in European Economic Area (EEA) countries or Switzerland. Treatment should be provided on the same

basis as it would be to a resident of that country and is provided in many cases either at reduced cost or,

for free. The EHIC covers treatment that is medically necessary until the card holder returns home. This

includes treatment for pre-existing medical conditions. The EHIC is not an alternative to travel insurance. It is important to have both an EHIC and a v alid travel insurance policy in place before you travel. Entitlement to an EHIC (in all EEA countries) is based on insurability under EU law, and not on a person's

nationality. The UK operates a residency-based healthcare system which means that insurability in the

UK is generally determined by residency and not by the past or present payment of National Insurance contributions or UK taxes.

If you are

not a UK, EU/EEA or Swiss national, you need to send evidence that you are ordinarily resident in the UK with your application. Proof could be a copy of your visa or UK residence permit.

If you are ordinarily resident and work in the UK, or if you are ordinarily resident in the UK and do not

work, then it is likely that you will be considered to be insured by the UK under EU law and will be entitled to apply for a UK EHIC.

There are special rules for pensioners who live abroad, pensioners living in the UK who get a pension

from an EEA country or Switzerland, students studying abroad, workers posted abroad by their employer, those who live in one country but work in another and those who live a nd/or work in more

than one country. If you fall into any of these categories or you are unsure about your eligibility for a UK

EHIC, please contact the enquiry line on 0300 330 1350 or +44 191 279 05

75 if calling from abroad.

If you are not eligible for a UK EHIC you may be eligible for an EHIC issued by a nother EEA country or

Switzerland if you are insured there.

If your circumstances change you may lose your entitlement to a UK EHIC. If you use your UK EHIC when you are no longer entitled to it, you may be liable for the full cost of treatment received. Circumstances that might lead to you losing your entitlement to a UK EHIC i nclude moving abroad, taking up work abroad or changing your residency status. 6/6

EHICS 0220

quotesdbs_dbs17.pdfusesText_23

[PDF] [PDF] Overseas Healthcare Services European Health Insurance Card

Overseas Healthcare Services

1/6How to complete this form

Street, Newcastle upon Tyne, NE1 6SN.

How we use your information

1. Declaration

UK EHIC. In these

EHICS 0220

1. Declaration (cont.)

NHS Counter Fraud Authority

Local Authorities

Credit reference agencies

Law enforcement organisations, as required by law

The Department for Work and Pensions

HM Revenue and Customs

NHS Commissioners and service providers

NHS England, Scotland, Wales and Northern Ireland

Department of Health and Social Care

NHS Counter Fraud Authority

I conrm that:

I am the main applicant

I am a representative for the main applicant

Permanent address of representative

If you are an organisation processing EHIC

If you fail to provide this information the

Signature Date

EHICS 0220

Current permanent address

House number (and/or house name):

Street:

County:

Postcode:Country:

Contact phone number (inc. area code):

Passport number:

How long have you lived in the UK?Number of years

Posted workers should answer 'No'

Yes No

EHIC Personal Identification Number (PIN): U K

2. The main applicant

Title:Mr Mrs MsMiss Other

Surname:

Forename(s):

Date of birth (must be aged 16 or over):

Nationality (if you are

4. Dependent children

Dependent child 1

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

Nationality:

Dependent child 2

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

Nationality:

EHICS 0220

3. Spouse/partner/civil partner

Title:Mr Mrs MsMiss Other

Surname:

Forename(s):

Date of birth:

Nationality:

EHICS 0220

4. Dependent children (cont.)

Dependent child 4

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

Nationality:

Dependent child 3

Title: Mr Ms

Surname:

Forename(s):

Date of birth:

Nationality:

Important information

If you are