Transmission of Request for Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence

DA006 - Transmission of Request for Authorisation to Receive Scheduled Treatment in a Member State Other Than the Competent Member State and the Member State of Residence
Articles 36, 20 of Regulation (EC) No 883/2004, 33, 26(2) of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Person *

Person Identification *

Family name(s) *

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Forename(s) *

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Date of birth *

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Sex *

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Family name(s) at birth

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Forename(s) at birth

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PIN of the person in each institution

Personal Identification Number(s) *

Country *

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Personal Identification Number (PIN) *

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Sector

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Institution

Institution ID *

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Institution Name *

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Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

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Region

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Country *

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Father's family name at birth

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Forename of father

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Mother's family name at birth

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Forename of mother

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Additional information on the person

Nationality

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Previous family name(s)

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Previous forename(s)

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Addresses of the person

Address of the person

Address

Street

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Building Name

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Town *

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Postal Code

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Region

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Country *

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Type of address

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Address of the person

This SED is related to *

Type Of SED *

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Date *

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Code

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Coding System

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Description

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Status of the Person

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Please fill in the following if "Status of the person" = "Other" :

Status of the person (if "Other")

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Employer

Name *

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Identification numbers

Identification number

Number *

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Type *

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Identification number

Address

Street

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Building Name

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Town *

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Postal Code

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Region

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Country *

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Treatment for which authorisation is requested *

Requested Treatment *

Description *

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Date of the care provider's request *

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Provider *

Name *

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Address *

Street

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Building Name

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Town *

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Postal Code

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Region

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Country *

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Period of treatment *

Start Date *

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End Date *

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The person can be treated within a medically justifiable time limit in the Member State of residence *

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Medical report *

Medical Report is attached *

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Additional information

Additional information

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