Claim for reimbursement (CLA)

S080 - Claim for reimbursement (CLA)
Articles 62, 66(1), 67 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Global Note CLA * [ SED ]

1.1. Global CLA Reference Creditor Liaison Body *

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1.2. Total number of individual claims *

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1.3. Total amount of benefits * [ CC ]

1.3.1. Amount *

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1.3.2. Currency *

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1.4. Half Year Number At Creditor Institution *

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1.5. Financial Year Number At Creditor Institution *

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1.6. Bank Account Creditor Liaison Body * [ CC ]

1.6.1. IBAN *

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1.6.2. BIC-SWIFT

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1.7. Date Of Submission *

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2. Individual CLAs * [ SED ]

2.1. Individual CLA * [ SED ]

2.1.1. ID Creditor Institution * [ CC ]

2.1.1.1. Institution ID *

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2.1.1.2. Institution Name *

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2.1.2. ID Debtor Institution * [ CC ]

2.1.2.1. Institution ID *

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2.1.2.2. Institution Name *

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2.1.3. References * [ SED ]

2.1.3.1. Global CLA Reference Creditor Liaison Body *

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2.1.3.2. Individual CLA number Creditor Liaison Body *

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2.1.3.3. Date Creditor Institution Recorded CLA *

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2.1.4. Person Receiving Benefits * [ CC ]

2.1.4.1. Person Information * [ CC ]

2.1.4.1.1. Family name(s) *

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2.1.4.1.2. Forename(s) *

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2.1.4.1.3. Date of birth *

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2.1.4.1.4. Sex *

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2.1.4.2. Family name(s) at birth

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2.1.4.3. Forename(s) at birth

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2.1.4.4. Person Identification Number * [ CC ]

2.1.4.4.1. PIN of the person in Competent Member State *

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

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2.1.5. Entitlement document * [ SED ]

2.1.5.1. Document *

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Please fill in the following if "Entitlement document" = "01 - EHIC - European Health Insurance Card" : [ SED ]

Please fill in the following if "Entitlement document" = "02 - PRC Provisional Replacement Certificate", "04 - S2 Entitlement to scheduled treatment", "08 - S045 Entitlement document - Temporary Stay" or "12 - E112 Certificate concerning the retention of the right to sickness or maternity benefits" : [ SED ]

Please fill in the following if "Entitlement document" <> "01 - EHIC - European Health Insurance Card", "02 - PRC Provisional Replacement Certificate", "04 - S2 Entitlement to scheduled treatment", "08 - S045 Entitlement document - Temporary Stay" or "12 - E112 Certificate concerning the retention of the right to sickness or maternity benefits" : [ SED ]

2.1.5.2.1. EHIC Number *

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2.1.5.2.2. Entitlement validity period * [ CC ]

2.1.5.2.2.1. Start date

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2.1.5.2.2.2. End date *

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2.1.5.3.1. Entitlement validity period * [ CC ]

2.1.5.3.1.1. Start Date *

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2.1.5.3.1.2. End Date *

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2.1.5.3.2. Date of issue *

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2.1.5.4.1. Entitlement validity period * [ CC ]

Fixed period* [ CC ]

Open period* [ CC ]

2.1.5.4.1.1.1. Start date *

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2.1.5.4.1.1.2. End date *

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2.1.5.4.1.2.1. Type of Open Period *

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2.1.5.4.1.2.2. Start date *

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2.1.5.4.2. Date of issue *

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2.1.6. Total individual amount of benefits * [ CC ]

2.1.6.1. Amount *

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2.1.6.2. Currency *

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2.1.7. Provided Benefits * [ SC ]

2.1.7.1. Nature of benefits *

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2.1.7.2. Benefits Period * [ CC ]

2.1.7.2.1. Start Date *

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2.1.7.2.2. End Date *

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2.1.7.3. All Benefits Amount * [ SC ]

2.1.7.3.1. Medical Care Amount

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2.1.7.3.2. Medicine Amount

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2.1.7.3.3. Dental Care Amount

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2.1.7.3.4. Long-term Care Amount

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2.1.7.3.5. Hospitalisation Benefits [ SC ]

2.1.7.3.5.1. Hospitalisation benefit [ SC ]

2.1.7.3.5.1.1. Hospitalisation period [ CC ]

2.1.7.3.5.1.1.1. Start Date *

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2.1.7.3.5.1.1.2. End Date *

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2.1.7.3.5.1.2. Hospitalisation Amount *

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2.1.7.3.5.1.Hospitalisation benefit

2.1.7.3.6. Other benefit(s) [ SC ]

2.1.7.3.6.1. Other benefit [ SC ]

2.1.7.3.6.1.1. Other Benefit Description *

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2.1.7.3.6.1.2. Other Benefits Amount *

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2.1.7.3.6.1.Other benefit

2.1.Individual CLA

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S080 - Claim for reimbursement (CLA) Articles 62, 66(1), 67 of Regulation (EC) No 987/2009

S080 - Claim for reimbursement (CLA)
Articles 62, 66(1), 67 of Regulation (EC) No 987/2009