S1/E121 EHIC renewal application form
Please note: By submitting this form you are declaring that you have a valid
S1/E121 which was issued to you for the country you currently reside in, due to you
receiving an exportable UK benefit.
This form is only for use by people who live abroad. If you live in the UK, please
visit www.nhs.uk/ehic for details of how to apply.
Name:
Title
First name(s)
Last name
Current address:
House
name/number
Street name
City
County/Region
Country
Post code
Previous address (if different to current address):
House
name/number
Street name
City
County/Region
Country
Post code
UK PIN Number (shown on your current EHIC):
UK
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Are your circumstances still the same as when you last applied for your EHIC?
Yes
No
If your circumstances are not the same as when you last applied for your EHIC,
please tell us about your change in circumstances:
Name and UK PIN of spouse/partner (if applicable):
Title
First name(s)
UK PIN (shown on current EHIC)
Last name
UK
Name(s) of dependent children living at your address (if applicable):
Title
First name(s)
Last name
UK PIN (shown on
current EHIC)
UK
UK
UK
UK
UK
You can only use this form to renew your EHIC via email - please attach to your
email and send to: [email protected]. We are unable to accept
this form by fax or post.
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