Request for Medical Information

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

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Person * [ SED ]

1.1. Person identification * [ CC ]

1.1.1. Family name(s) *

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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 *

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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 [ SED ]

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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1.2.4. Address [ CC ]

1.2.4.1. Street

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1.2.4.2. Building Name

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

1.2.4.3. Town *

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

1.2.4.4. Postal Code

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

1.2.4.5. Region

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1.2.4.6. Country *

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1.2.5. Contact information on the person [ CC ]

1.2.5.1. Telephone Numbers [ CC ]

1.2.5.1.1. Telephone Number [ CC ]

1.2.5.1.1.1. Type

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

1.2.5.1.1.2. Number *

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

1.2.5.1.1.Telephone Number

1.2.5.2. Email Addresses [ CC ]

1.2.5.2.1. Email Address [ CC ]

1.2.5.2.1.1. Email Address

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1.2.5.2.1.Email Address

2. The benefit concerned * [ SED ]

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

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3. Nature of request * [ SED ]

3.1. We ask you to *

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3.2. Please provide

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

3.3.1. Other Medical Evidence

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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 * [ SED ]

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

4.1.1. Start Date *

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4.1.2. End Date *

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

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6. Questions for family benefits only [ SED ]

6.1. Requested information *

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6.2. Additional information to medical report

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7. Questions for AWOD only [ SED ]

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

7.1.1. This SED is related to *

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7.1.2. Date *

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7.1.3. Accident/disease code

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7.1.4. Accident/disease coding system

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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

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

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

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7.1.8. Employer * [ CC ]

7.1.8.1. Name *

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

7.1.8.2. Identification numbers [ CC ]

7.1.8.2.1. Identification number [ CC ]

7.1.8.2.1.1. Number *

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

7.1.8.2.1.2. Type *

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

7.1.8.2.1.Identification number

7.1.8.3. Address [ CC ]

7.1.8.3.1. Street

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

7.1.8.3.2. Building Name

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

7.1.8.3.3. Town *

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

7.1.8.3.4. Postal Code

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

7.1.8.3.5. Region

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

7.1.8.3.6. Country *

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

8. Additional information [ SED ]

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