Information About Granting of Authorisation to Receive Scheduled Urgent Vitally Necessary Treatment by the Institution in the Member State of Residence on Behalf of the Competent Institution

DA009 - Information About Granting of Authorisation to Receive Scheduled Urgent Vitally Necessary Treatment by the Institution in the Member State of Residence on Behalf of the Competent Institution
Articles 36, 20 of Regulation (EC) No 883/2004, 33, 26(3) 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) *

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

1.1.2. Forename(s) *

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

1.1.3. Date of birth *

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

1.1.4. Sex *

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

1.1.5. Family name(s) at birth

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

1.1.6. Forename(s) at birth

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

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) *

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

1.1.7.1.3. Sector

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

1.1.7.1.4. Institution [ CC ]

1.1.7.1.4.1. Institution ID *

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

1.1.7.1.4.2. Institution Name *

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

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 *

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

1.1.8.1.2. Region

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

1.1.8.1.3. Country *

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

1.1.8.2. Father's family name at birth

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

1.1.8.3. Forename of father

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

1.1.8.4. Mother's family name at birth

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

1.1.8.5. Forename of mother

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

1.2. Additional information on the person [ SC ]

1.2.1. Nationality

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

1.2.2. Previous family name(s)

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

1.2.3. Previous forename(s)

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

2. Addresses of the person [ SC ]

2.1. Address of the person [ SC ]

2.1.1. Address [ CC ]

2.1.1.1. Street

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

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

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

2.1.1.5. Region

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

2.1.1.6. Country *

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

2.1.2. Type of address

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

2.1.Address of the person

3. This SED is related to * [ SC ]

3.1. Type Of SED *

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

3.2. Date *

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

3.3. Code

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

3.4. Coding System

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

3.5. Description

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

3.6. Status of the Person

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

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

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

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

4. Employer [ CC ]

4.1. Name *

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

4.2. Identification numbers [ CC ]

4.2.1. Identification number [ CC ]

4.2.1.1. Number *

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

4.2.1.2. Type *

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

4.2.1.Identification number

4.3. Address [ CC ]

4.3.1. Street

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

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

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

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 was granted * [ 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 *

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

5.4.2. End Date *

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

6. Additional information [ SED ]

6.1. Attachment

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

6.2. Additional information [ SC ]

6.2.1. Additional information

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

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

DA009 - Information About Granting of Authorisation to Receive Scheduled Urgent Vitally Necessary Treatment by the Institution in the Member State of Residence on Behalf of the Competent Institution Articles 36, 20 of Regulation (EC) No 883/2004, 33, 26(3) of Regulation (EC) No 987/2009

DA009 - Information About Granting of Authorisation to Receive Scheduled Urgent Vitally Necessary Treatment by the Institution in the Member State of Residence on Behalf of the Competent Institution
Articles 36, 20 of Regulation (EC) No 883/2004, 33, 26(3) of Regulation (EC) No 987/2009