Microsoft Word - LTI APP.doc

APPLICATION FORM

LONG TERM ILLNESS SCHEME

The Long Term Illness Scheme applies only to persons suffering from any of the

following diseases or disabilities: Mental Handicap; Mental illness ( for persons under 16

yrs only); Phenylketonuria; Cystic Fibrosis; Spina Bifida and Hydrocephalus;

Haemophilia; Cerebral Palsy; Epilepsy; Diabetes Melitus and Diabetes Insipidus;

Parkinson’s Disease; Acute Leukaemia; Muscular Dystrophy; Multiple Sclerosis.

PART I – To be completed by applicant:

I wish to apply for benefit under the above scheme:- (USE BLOCK CAPITALS)

SURNAME:_____________________ FIRSTNAME: ______________________

BIRTH SURNAME: _________________ PHONE NO.___________________________

ADDRESS:________________________________________________________

MOTHERS MAIDEN NAME: _______________DATE OF BIRTH: ____________

PPSN NO (RSI NO): __________________________

DO YOU HAVE A MEDICAL CARD? YES NO MEDICAL CARD NO: ________

NAME and ADDRESS OF GP/ FAMILY DOCTOR:______________________________

NAME OF HOSPITAL/CONSULTANT: ___________________________________

NAME and ADDRESS OF PHARMACY: _________________________________

SIGNATURE OF APPLICANT: _________________________________________

Or parent/guardian if aged under 16 years

PART II – To completed by applicant’s doctor/consultant

I certify that ________ is under my care for the treatment of______________________

(Insert medical condition) and his/her present requirements for the treatment of the

conditions are as follows:

Medical Preparation Dosage Quantity

Doctor/Hospital

Stamp

Please add additional pages as required.

Signature of Doctor/Consultant: _______________________Date: ________________

PART III – For official use only:

Application approved by: ____________________Grade: ________________________

Date: ___________________ Authorisation Number Assigned______________