Department of Social Protection

Treatment Benefit Consent

Please complete this form to authorise Trim Optical Centre to check your eligibility for Treatment Benefit and to process payment claims for treatments you have received.

First Name(s) *

Family Name *

Date of Birth *

PPS Number *

Medical Card No. (if applicable)

Children's name(s) (if checking children's eligibility)

Email Address *

Mobile Telephone Number *

Home Address *

Agreement: I, the undersigned, authorise Trim Optical Centre to use my personal data for the purposes of checking my eligibility for Treatment Benefits and to allow for the processing of payment claims in respect of treatments I have received.

YesNo

I understand that I may revoke this consent at any time by contacting the Department of Social Protection and/or HSE.

Signature (type your full name) *

Date of Signature *

Thank you! Your submission has been received!

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