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Under 16 Details
Applicant 1 Details (under 16)
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Under 16 Applicant Contact Details
Tick this box if you DO NOT have an email address.
Guardian / Parent Details
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Guardian / Parent National Insurance, NHS or CHI Number

Please supply only a valid National Insurance, NHS or CHI Number otherwise your cover will not be valid.

IMPORTANT: Select this option if you can't remember your National Insurance, NHS or CHI Number.

(We will contact you to obtain the omitted information above. You will need to provide this before we can process your application.)

EHIC Declaration:

Please read this declaration carefully before accepting it. By making this declaration I agree to the following statements:

I understand that should the main applicant have a change to residency status , move abroad to live or take up work abroad then he or she may no longer be entitled to a UK EHIC. In these circumstances the relevant authorities should 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 mentioned on this application.

I understand that this card 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 declare that I have read and understood the eligibility requirements for receiving an EHIC. 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.

I understand that the administration of the EHIC and responsibility for counter fraud and security management in the NHS are both responsibilities 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 NHS Protect, a division of NHSBSA, and other NHS organisations and government agencies may use the information on this form and otherwise in connection with this application for the purposes of the prevention, detection and investigation of fraud and error affecting the NHS. The information can also be used for the purposes of prosecution of fraud.

I agree to the disclosure of information on this form for the purposes of verification and, in compliance with the Data Protection Act, to and from other organisations including:

- Local Authorities to which Council Tax is paid in respect of my dwelling throughout the United Kingdom

- Organisations from which I am receiving benefits and/or support

- The Department for Work and Pensions

- HM Revenue and Customs

- Credit reference agencies

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

In continuing with this application, I confirm that:

The main applicant specified in this application has British, EU, EEA or Swiss nationality.

The main applicant specified 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 details being disclosed.

I agree to the terms of the Data Protection Statement set out here. (View)

I agree to the use of cookies as described here. (View)

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