Request for Medical Information

H120 - Request for Medical Information
Regulation (EEC) No 883/04

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

1. Person *

1.1. Person identification *

1.1.1. Family name(s) *

1.1.2. Forename(s) *

1.1.3. Date of birth *

1.1.4. Sex *

1.1.5. Family name(s) at birth

1.1.6. Forename(s) at birth

1.1.7. PIN of the person in each institution

1.1.7.1. Personal Identification Number(s) *

1.1.7.1.1. Country *

1.1.7.1.2. Personal Identification Number (PIN) *

1.1.7.1.3. Sector

1.1.7.1.4. Institution

1.1.7.1.4.1. Institution ID *

1.1.7.1.4.2. Institution Name *

1.1.7.1.Personal Identification Number(s)

1.1.8. If PIN not provided for every institution, please provide

1.1.8.1. Place of birth

1.1.8.1.1. Town *

1.1.8.1.2. Region

1.1.8.1.3. Country *

1.1.8.2. Father's family name at birth

1.1.8.3. Forename of father

1.1.8.4. Mother's family name at birth

1.1.8.5. Forename of mother

1.2. Additional information on the person

1.2.1. Nationality

1.2.2. Previous family name(s)

1.2.3. Previous forename(s)

1.2.4. Address

1.2.4.1. Street

1.2.4.2. Building Name

1.2.4.3. Town *

1.2.4.4. Postal Code

1.2.4.5. Region

1.2.4.6. Country *

1.2.5. Contact information on the person

1.2.5.1. Telephone Numbers

1.2.5.1.1. Telephone Number

1.2.5.1.1.1. Type

1.2.5.1.1.2. Number *

1.2.5.1.1.Telephone Number

1.2.5.2. Email Addresses

1.2.5.2.1. Email Address

1.2.5.2.1.1. Email Address

1.2.5.2.1.Email Address

2. The benefit concerned *

2.1. Type of benefit in refer to which the medical information is requested *

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3. Nature of request *

3.1. We ask you to *

3.2. Please provide

3.3. Please fill in the following if "Please provide" = "Other Medical Evidence" :

3.3.1. Other Medical Evidence

3.4. Description (special requirements to be followed and points to be covered) of the requested medical examination

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4. Period concerned *

4.1. The requested Medical evidence/ examination concerns the period of incapacity for work *

4.1.1. Start Date *

4.1.2. End Date *

5. We agree to cover the costs of the medical evidence/examination *

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6. Questions for family benefits only

6.1. Requested information *

6.2. Additional information to medical report

7. Questions for AWOD only

7.1. Please fill in the following section only if the request concerns an accident at work or an occupational disease:

7.1.1. This SED is related to *

7.1.2. Date *

7.1.3. Accident/disease code

7.1.4. Accident/disease coding system

7.1.5. Consequences of the accident / kind or short description of the disease

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7.1.6. Status of the person

7.1.7. Please fill in the following if "Status of the person" = "Other" :

7.1.7.1. Status of the person (if "Other")

7.1.8. Employer *

7.1.8.1. Name *

7.1.8.2. Identification numbers

7.1.8.2.1. Identification number

7.1.8.2.1.1. Number *

7.1.8.2.1.2. Type *

7.1.8.2.1.Identification number

7.1.8.3. Address

7.1.8.3.1. Street

7.1.8.3.2. Building Name

7.1.8.3.3. Town *

7.1.8.3.4. Postal Code

7.1.8.3.5. Region

7.1.8.3.6. Country *

8. Additional information

8.1. Additional information

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H120 - Request for Medical Information Regulation (EEC) No 883/04

H120 - Request for Medical Information
Regulation (EEC) No 883/04