Claim for - Reimbursement - Administrative Check /Medical information

H020 - Claim for - Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Global Claim *

Creditor institution *

Institution ID *

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Institution Name *

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Global Reference set by Creditor Institution *

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Total number of invoices *

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Total Claim amount in currency of creditor institution *

Amount *

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Currency *

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Payment due on

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Debtor institution

Institution ID *

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Institution Name *

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Bank details

IBAN *

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BIC-SWIFT

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Claim

Person *

Person Information *

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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Person Identification Number *

PIN of the person in Competent Member State *

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PIN of the person in Member State of Stay or Residence

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Reimbursement *

In reference to your *

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Issued on *

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Invoice number of creditor institution *

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Invoice amount in currency of creditor institution *

Amount *

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Currency *

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Reimbursement

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