Reply to Contestation of Credit Note (RPY_COC

DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN)
Articles 35, 41 of Regulation (EC) No 883/2004, 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 RPY_COC_CRN *

Global CLA reference Creditor Liaison Body *

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Global CRN reference Creditor Liaison Body *

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Global COC_CRN reference Debtor Liaison Body *

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Global RPY_COC_CRN reference Creditor Liaison Body *

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Total Number Of Individual RPY_COC_CRN *

Total amount of accepted credit notes contestations *

Amount *

Currency *

Date Of Submission *

Individual RPY COC CRNs *

Individual RPY_COC_CRN *

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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Global CRN Reference Creditor Liaison Body *

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Global COC_CRN Reference Debtor Liaison Body *

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Global RPY_COC_CRN Reference Creditor Liaison Body *

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Individual CLA Number Creditor Liaison Body *

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Individual CRN Number Creditor Liaison Body *

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Individual COC_CRN Number Debtor Liaison Body *

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Individual RPY_COC_CRN Number Creditor Liaison Body *

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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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Reply to credit note contestation *

Please fill in the following if "Reply to credit note contestation" = "01 - Rectified corresponding claim number" :
Please fill in the following if "Reply to credit note contestation" = "03 - We accept contestation" :
Please fill in the following if "Reply to credit note contestation" = "02 - Credit note correction" :
Please fill in the following if "Reply to credit note contestation" = "99 - Other [field Other should be filled in]"

Rectified claim number *

Amount of accepted contestation of credit note

Amount *

Currency *

Credit Note Correction

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

Adjusted Amount of Credit Note *

Amount *

Currency *

Other *

Individual RPY_COC_CRN

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DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN) Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009