Claim for reimbursement (CLA)

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

SED API version: 0.16.2 build 2
Model version: 4.2.0

Global Note CLA *

Global CLA Reference Creditor Liaison Body *

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Total number of individual claims *

Total amount of benefits *

Amount *

Currency *

Half Year Number At Creditor Institution *

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Financial Year Number At Creditor Institution *

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Bank Account Creditor Liaison Body *

IBAN *

BIC-SWIFT

Date Of Submission *

Individual CLAs *

Individual CLA *

ID Creditor Institution *

Institution ID *

Institution Name *

ID Debtor Institution *

Institution ID *

Institution Name *

References *

Global CLA Reference Creditor Liaison Body *

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Individual CLA number Creditor Liaison Body *

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Date Creditor Institution Recorded CLA *

Person Receiving Benefits *

Person Information *

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

Person Identification Number *

PIN of the person in Competent Member State *

PIN of the person in Member State of Stay or Residence

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Entitlement document *

Document *

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

EHIC Number *

Entitlement validity period *

Start date

End date *

Entitlement validity period *

Start Date *

End Date *

Date of issue *

Entitlement validity period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Date of issue *

Total individual amount of benefits *

Amount *

Currency *

Provided Benefits *

Nature of benefits *

Benefits Period *

Start Date *

End Date *

All Benefits Amount *

Medical Care Amount

Medicine Amount

Dental Care Amount

Long-term Care Amount

Hospitalisation Benefits

Hospitalisation benefit

Hospitalisation period

Start Date *

End Date *

Hospitalisation Amount *

Hospitalisation benefit

Other benefit(s)

Other benefit

Other Benefit Description *

Other Benefits Amount *

Other benefit

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