Request for Medical Information

H120 - Request for Medical Information
Regulation (EEC) No 883/04

SED API version: 0.16.2 build 2
Model version: 4.2.0

Person *

Person identification *

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

PIN of the person in each institution

Personal Identification Number(s) *

Country *

Personal Identification Number (PIN) *

Sector

Institution

Institution ID *

Institution Name *

Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

Region

Country *

Father's family name at birth

Forename of father

Mother's family name at birth

Forename of mother

Additional information on the person

Nationality

Previous family name(s)

Previous forename(s)

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Contact information on the person

Telephone Numbers

Telephone Number

Type

Number *

Telephone Number

Email Addresses

Email Address

The benefit concerned *

Type of benefit in refer to which the medical information is requested *

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Nature of request *

We ask you to *

Please provide

Please fill in the following if "Please provide" = "Other Medical Evidence" :

Other Medical Evidence

Description (special requirements to be followed and points to be covered) of the requested medical examination

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Period concerned *

The requested Medical evidence/ examination concerns the period of incapacity for work *

Start Date *

End Date *

We agree to cover the costs of the medical evidence/examination *

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Questions for family benefits only

Requested information *

Additional information to medical report

Questions for AWOD only

Please fill in the following section only if the request concerns an accident at work or an occupational disease:

This SED is related to *

Date *

Accident/disease code

Accident/disease coding system

Consequences of the accident / kind or short description of the disease

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Status of the person

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

Status of the person (if "Other")

Employer *

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Additional information

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H120 - Request for Medical Information Regulation (EEC) No 883/04

H120 - Request for Medical Information
Regulation (EEC) No 883/04