Apply

Download the application form in English or Irish or LoCall 0818 22 44 78 to order one.

Send the completed application form to:

LTI Client Registration Unit
PO Box 12962
Dublin 11
D11 XFF3

What to include in your application

Your doctor or consultant will need to sign the form and provide a medical report.

On the form, they will list any:

  • long-term illness conditions you have
  • medication and appliances you need to treat your condition

You will need to provide the following personal information:

  • Full name
  • Address
  • PPS number

Information

Incomplete applications take longer to process. This is because we may need to contact you for more information.

Information:

Related content

Long Term Illness Scheme Application Form (PDF, 413KB, 6 pages)

To apply for the long-term illness scheme, download this application form, complete and return to your local Community Health Organisation - English version

Scéim na dTinneas Fadtéarmach - Foirm Iarratais - Long-Term Illness Scheme (PDF 1.19MB, 6 pages)

To apply for the long-term illness scheme, download this application form, complete and return to your local Community Health Organisation - Irish version

Page last reviewed: 28 May 2019
Next review due: 28 May 2022