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Maternity benefit form mb3

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The document is a Medical Certificate for Maternity Benefit (MB 3) required for self-employed or unemployed individuals in Ireland, certifying the expected birth date after week 24 of pregnancy. It includes sections for patient and doctor information, data protection statements, and instructions for completing the form.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's PPS Number in the designated field. This is essential for identification purposes.
Next, fill in the patient's name clearly in the provided space to ensure accurate documentation.
Indicate the expected date of birth by selecting the day, month, and year from the respective fields.
Record the date of examination in the specified area to document when the assessment took place.
The doctor should enter their name, DSP panel number, IMC number, address, phone number, and email address accurately.
Finally, ensure that the doctor provides their official stamp and signature at the bottom of the form to validate it.
If any changes are made after completion, initial and date those amendments to maintain acceptance of information.

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