Reply to Claim for Reimbursement - Administrative Check /Medical information

H021 - Reply to 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 *

Institution Name *

Global Reference set by Creditor Institution *

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Global Reference set by Debtor Institution *

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Total number of invoices *

Payment

Total Claim Amount in currency of creditor institution *

Amount *

Currency *

Total Claim Amount Rejected In Creditor Currency

Amount *

Currency *

Total Payment In Creditor Currency *

Amount *

Currency *

Payment reference for transfer to creditor institution

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Claim

Person *

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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Reimbursement *

In reference to our *

Issued on *

Invoice number of creditor institution *

Invoice amount in currency of creditor institution *

Amount *

Currency *

Rejection:

Detail of Partial or Full Rejection

Invoice Amount Rejected in currency of creditor institution

Amount *

Currency *

Rejection reason

Please fill in the following if "Rejection reason" = "Other"

Other

Reimbursement

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H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information Article 87 of Regulation (EC) No 987/2009

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009