Claim for - Reimbursement - Administrative Check /Medical information

H020 - Claim for - Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Global Claim * [ SED ]

1.1. Creditor institution * [ CC ]

1.1.1. Institution ID *

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1.1.2. Institution Name *

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1.2. Global Reference set by Creditor Institution *

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1.3. Total number of invoices *

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1.4. Total Claim amount in currency of creditor institution * [ SED ]

1.4.1. Amount *

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1.4.2. Currency *

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1.4.3. Payment due on

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1.5. Debtor institution [ CC ]

1.5.1. Institution ID *

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1.5.2. Institution Name *

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1.6. Bank details [ CC ]

1.6.1. IBAN *

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1.6.2. BIC-SWIFT

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2. Claim [ SED ]

2.1. Person * [ CC ]

2.1.1. Person Information * [ CC ]

2.1.1.1. Family name(s) *

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2.1.1.2. Forename(s) *

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2.1.1.3. Date of birth *

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2.1.1.4. Sex *

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2.1.2. Family name(s) at birth

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2.1.3. Forename(s) at birth

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2.1.4. Person Identification Number * [ CC ]

2.1.4.1. PIN of the person in Competent Member State *

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

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2.2. Reimbursement * [ SED ]

2.2.1. In reference to your *

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2.2.2. Issued on *

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2.2.3. Invoice number of creditor institution *

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2.2.4. Invoice amount in currency of creditor institution * [ CC ]

2.2.4.1. Amount *

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2.2.4.2. Currency *

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2.2.Reimbursement

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H020 - Claim for - Reimbursement - Administrative Check /Medical information Article 87 of Regulation (EC) No 987/2009

H020 - Claim for - Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009