Notification of Medical Information / Reply to request for Medical Information

H121 - Notification of Medical Information / Reply to request for Medical Information
Articles 21, 34, 36(3), 82 of Regulation (EC) No 883/2004; Articles 27(5)(6)(10),28 (3)(5), 33(1), 87(1)(2)(4) of Regulation (EC) No 987/2009

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

Reply to request for estimated costs of Medical Evidence/Examination
Reply to request for Medical Examination/Report
Reply to request for Medical Evidence
Notification of Medical Information

2.1. Reply to request for estimated costs of Medical Evidence/Examination

2.1.1. In reply to your request concerning estimated costs of the medical evidence/ examination we inform that the estimated costs are *

{{metaSection.replyForEstimatedCostsForMedicalEvidenceExamination.$$error}} {{metaSection.replyForEstimatedCostsForMedicalEvidenceExamination.$$warning}}

2.1.2. Currency *

3.1. Reply to request for Medical Examination/Report

3.1.1. In reply to your request concerning the medical examination we inform you that it *

{{metaSection.inReplyRequestConcerningMedicalExaminationInformIt.$$error}} {{metaSection.inReplyRequestConcerningMedicalExaminationInformIt.$$warning}}

3.1.2. Reason for not carrying out the medical examination

{{metaSection.reasonForNotCarryingOutMedicalExamination.$$error}} {{metaSection.reasonForNotCarryingOutMedicalExamination.$$warning}}

3.1.3. Please fill in the following if "Reason for not carrying out the medical examination" = "Other" :

3.1.3.1. Other reason

4.1. Reply to request for Medical Evidence

4.1.1. In reply to your request for the medical evidence, we attached the requested medical evidence. *

{{metaSection.replyAttachedRequestedMedicalEvidenceIndicator.$$error}} {{metaSection.replyAttachedRequestedMedicalEvidenceIndicator.$$warning}}

4.1.2. Reasons for not sending the requested medical evidence

{{metaSection.reasonsForNotSendingRequestedMedicalEvidence.$$error}} {{metaSection.reasonsForNotSendingRequestedMedicalEvidence.$$warning}}

5.1. Notification of Medical Information

5.1.1. Please find attached: *

5.1.2. Other medical information

6. Additional information

6.1. Additional information

{{ row.severityMessage }} : {{ row.message }}

H121 - Notification of Medical Information / Reply to request for Medical Information Articles 21, 34, 36(3), 82 of Regulation (EC) No 883/2004; Articles 27(5)(6)(10),28 (3)(5), 33(1), 87(1)(2)(4) of Regulation (EC) No 987/2009

H121 - Notification of Medical Information / Reply to request for Medical Information
Articles 21, 34, 36(3), 82 of Regulation (EC) No 883/2004; Articles 27(5)(6)(10),28 (3)(5), 33(1), 87(1)(2)(4) of Regulation (EC) No 987/2009