Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence

DA007 - Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence
Articles 36, 20 of Regulation (EC) No 883/2004, 33(1) and (2), 26(2) of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Person * [ SC ]

1.1. Person Identification * [ CC ]

1.1.1. Family name(s) *

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1.1.2. Forename(s) *

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1.1.3. Date of birth *

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1.1.4. Sex *

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1.1.5. Family name(s) at birth

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1.1.6. Forename(s) at birth

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1.1.7. PIN of the person in each institution [ CC ]

1.1.7.1. Personal Identification Number(s) * [ CC ]

1.1.7.1.1. Country *

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1.1.7.1.2. Personal Identification Number (PIN) *

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1.1.7.1.3. Sector

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1.1.7.1.4. Institution [ CC ]

1.1.7.1.4.1. Institution ID *

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1.1.7.1.4.2. Institution Name *

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1.1.7.1.Personal Identification Number(s)

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

1.1.8.1. Place of birth [ CC ]

1.1.8.1.1. Town *

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1.1.8.1.2. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

1.1.8.1.3. Country *

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1.1.8.2. Father's family name at birth

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1.1.8.3. Forename of father

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1.1.8.4. Mother's family name at birth

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1.1.8.5. Forename of mother

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1.2. Additional information on the person [ SC ]

1.2.1. Nationality

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1.2.2. Previous family name(s)

[ BDT ] {{metaSection.previousFamilyName.$$error}} {{metaSection.previousFamilyName.$$warning}}

1.2.3. Previous forename(s)

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2. Addresses of the person [ SC ]

2.1. Address of the person [ SC ]

2.1.1. Address [ CC ]

2.1.1.1. Street

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2.1.1.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

2.1.1.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

2.1.1.4. Postal Code

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2.1.1.5. Region

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2.1.1.6. Country *

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2.1.2. Type of address

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2.1.Address of the person

3. This SED is related to * [ SC ]

3.1. Type Of SED *

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3.2. Date *

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3.3. Code

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3.4. Coding System

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3.5. Description

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3.6. Status of the Person

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3.7. Please fill in the following if "Status of the person" = "Other" : [ SC ]

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

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4. Employer [ CC ]

4.1. Name *

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4.2. Identification numbers [ CC ]

4.2.1. Identification number [ CC ]

4.2.1.1. Number *

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4.2.1.2. Type *

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4.2.1.Identification number

4.3. Address [ CC ]

4.3.1. Street

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4.3.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

4.3.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

4.3.4. Postal Code

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4.3.5. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

4.3.6. Country *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

5. Treatment for which authorisation is requested * [ SC ]

5.1. Description *

[ CDT ] {{metaSection.description.$$error}} {{metaSection.description.$$warning}}

5.2. Date of the person's request *

[ BDT ] {{metaSection.datePersonRequest.$$error}} {{metaSection.datePersonRequest.$$warning}}

5.3. Provider * [ SC ]

5.3.1. Name *

[ CDT ] {{metaSection.name.$$error}} {{metaSection.name.$$warning}}

5.3.2. Address * [ CC ]

5.3.2.1. Street

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

5.3.2.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

5.3.2.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

5.3.2.4. Postal Code

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

5.3.2.5. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

5.3.2.6. Country *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

5.4. Period of treatment * [ CC ]

5.4.1. Start Date *

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5.4.2. End Date *

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6. Authorisation to receive scheduled treatment * [ SED ]

6.1. Authorisation to receive the treatment described above is hereby *

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6.2. Please fill in the following if "Authorisation to receive the treatment described above is hereby " = "Refused" [ SED ]

6.2.1. Reason for refusal - if applicable

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6.2.2. Please fill in the following if "Reason for refusal (if applicable) " = "Other" : [ SED ]

6.2.2.1. Other

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7. Additional information [ SC ]

7.1. Additional information

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DA007 - Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence Articles 36, 20 of Regulation (EC) No 883/2004, 33(1) and (2), 26(2) of Regulation (EC) No 987/2009

DA007 - Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence
Articles 36, 20 of Regulation (EC) No 883/2004, 33(1) and (2), 26(2) of Regulation (EC) No 987/2009