Reply to request for Entitlement Document - scheduled treatment outside Member State of residence

S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence
Articles 20, 27 (3) of Regulation (EC) No 883/2004; Article 26 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

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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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2. Person's address [ CC ]

2.1. Street

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2.2. Building Name

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2.3. Town *

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2.4. Postal Code

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2.5. Region

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2.6. Country *

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Authorisation for scheduled treatment is granted* [ SED ]

Authorisation for scheduled treatment is not granted* [ SED ]

3.1. Starting and/or ending date of the entitlement * [ CC ]

3.1.1. Start Date *

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3.1.2. End Date *

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3.2. Additional information on treatment * [ SC ]

3.2.1. Description *

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3.2.2. Date of the request by person *

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

3.2.3. Provider * [ SC ]

3.2.3.1. Name *

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

3.2.3.2. Address * [ CC ]

3.2.3.2.1. Street

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

3.2.3.2.2. Building Name

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

3.2.3.2.3. Town *

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3.2.3.2.4. Postal Code

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3.2.3.2.5. Region

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

3.2.3.2.6. Country *

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3.3. Entitlement document is attached

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4.1. Reason

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4.2. Please fill in the following if "Reason" = "Other reason" : [ SC ]

4.2.1. Other reason

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S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence Articles 20, 27 (3) of Regulation (EC) No 883/2004; Article 26 of Regulation (EC) No 987/2009

S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence
Articles 20, 27 (3) of Regulation (EC) No 883/2004; Article 26 of Regulation (EC) No 987/2009