Cost of Medical Care in respect of an Occupational Accident or Disease Application Form (C1)

• Published date: 23 April 2021
• Issuer: Department of Social Protection

Data Classification R

Social Welfare Services

C1

Application form for

Medical Care scheme

What is the Medical Care scheme?

The Medical Care scheme is a benet under the Occupational Injuries Scheme. If you are injured at work,

on an unbroken journey to or from work, or you contract a prescribed occupational disease while insured,

the Medical Care scheme may refund any costs not covered by the HSE or the Treatment Benet scheme.

Under the scheme, payment is made for certain medical expenses which have reasonably and necessarily

resulted from an occupational accident or the development of a prescribed occupational disease. It is

normally a once-o payment, but if the treatment is ongoing payment may be made in a few installments.

How do I qualify?

To qualify, you must:

• have been injured as a result of your work; or

• have been on an unbroken journey to or from work; or

• have contracted a prescribed occupational disease which developed due to the nature of your

employment; and

• be employed at PRSI class A, B, D, J, or M for employees under 16 years of age only.

Note: You must notify the department within 6 weeks of starting medical treatment.

How to complete this application form?

There is an example on the back of this page that can be used as a guide to ll in this form. Please:

• write with a black ballpoint pen, use capital letters and place an X in the relevant boxes;

• ll in Parts 1 to 5 and answer all questions that apply to you. Leave blank any that do not apply; and

• sign the declaration.

How do I apply?

Send this completed application form to:

Medical Care Section

Department of Social Protection

Áras Mhic Dhiarmada

Store Street

Dublin 1

D01 WY03

How can I get help and further information?

If you need any help to complete this form, please contact the Medical Care Section on 0818 928 400 or

(01) 704 3000, or your local Intreo Centre, Social Welfare Oce or any Citizens Information Centre.

You can nd the name and address of your local Intreo Centre or Social Welfare Oce by visiting

www.gov.ie/intreocentres.

For more information visit www.gov.ie/medcarescheme.