Reply to Claim for Reimbursement - Administrative Check /Medical information

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009

SED API version: 0.15.3 build preview 1
Model version: 4.1.0

1. Global Claim *

1.1. Creditor institution *

1.1.1. Institution ID *

1.1.2. Institution Name *

1.2. Global Reference set by Creditor Institution *

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1.3. Global Reference set by Debtor Institution *

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1.4. Total number of invoices *

1.5. Payment

1.5.1. Total Claim Amount in currency of creditor institution *

1.5.1.1. Amount *

1.5.1.2. Currency *

1.5.2. Total Claim Amount Rejected In Creditor Currency

1.5.2.1. Amount *

1.5.2.2. Currency *

1.5.3. Total Payment In Creditor Currency *

1.5.3.1. Amount *

1.5.3.2. Currency *

1.5.4. Payment reference for transfer to creditor institution

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2. Claim

2.1. Person *

2.1.1. Person Information *

2.1.1.1. Family name(s) *

2.1.1.2. Forename(s) *

2.1.1.3. Date of birth *

2.1.1.4. Sex *

2.1.2. Family name(s) at birth

2.1.3. Forename(s) at birth

2.1.4. Person Identification Number *

2.1.4.1. PIN of the person in Competent Member State *

2.1.4.2. PIN of the person in Member State of Stay or Residence

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2.2. Reimbursement *

2.2.1. In reference to our *

2.2.2. Issued on *

2.2.3. Invoice number of creditor institution *

2.2.4. Invoice amount in currency of creditor institution *

2.2.4.1. Amount *

2.2.4.2. Currency *

2.2.5. Rejection:

2.2.6. Detail of Partial or Full Rejection

2.2.6.1. Invoice Amount Rejected in currency of creditor institution

2.2.6.1.1. Amount *

2.2.6.1.2. Currency *

2.2.7. Rejection reason

2.2.8. Please fill in the following if "Rejection reason" = "Other"

2.2.8.1. Other

2.2.Reimbursement

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H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information Article 87 of Regulation (EC) No 987/2009

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009