Talba għal Informazzjoni Medika

H120 - Talba għal Informazzjoni Medika
Ir-Regolament (KE) Nru 883/04

SED API version: 0.16.2 build 2
Model version: 4.2.0

Persuna * [ SED ]

Identifikazzjoni tal-persuna * [ CC ]

Kunjom(ijiet) *

[ BDT ] {{metaSection.familyName.$$error}} {{metaSection.familyName.$$warning}}

Isem/ismijiet *

[ BDT ] {{metaSection.forename.$$error}} {{metaSection.forename.$$warning}}

Data tat-twelid *

[ BDT ] {{metaSection.dateBirth.$$error}} {{metaSection.dateBirth.$$warning}}

Sess *

[ ENUM ] {{metaSection.sex.$$error}} {{metaSection.sex.$$warning}}

Kunjom(ijiet) mat-twelid

[ BDT ] {{metaSection.familyNameAtBirth.$$error}} {{metaSection.familyNameAtBirth.$$warning}}

Isem/ismijiet mat-twelid

[ BDT ] {{metaSection.forenameAtBirth.$$error}} {{metaSection.forenameAtBirth.$$warning}}

PIN tal-persuna f’kull istituzzjoni [ CC ]

Numru/i ta' Identifikazzjoni Personali * [ CC ]

Pajjiż *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Numru ta' identifikazzjoni personali (PIN) *

[ BDT ] {{metaSection.personalIdentificationNumber.$$error}} {{metaSection.personalIdentificationNumber.$$warning}}

Settur

[ ENUM ] {{metaSection.sector.$$error}} {{metaSection.sector.$$warning}}

Istituzzjoni [ CC ]

ID tal-istituzzjoni *

[ BDT ] {{metaSection.institutionID.$$error}} {{metaSection.institutionID.$$warning}}

Isem l-istituzzjoni *

[ CDT ] {{metaSection.institutionName.$$error}} {{metaSection.institutionName.$$warning}}

Numru/i ta' Identifikazzjoni Personali

Jekk il-PIN ma ġiex ipprovdut għal kull istituzzjoni, jekk jogħġbok ipprovdi [ CC ]

Post tat-twelid [ CC ]

Belt *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Reġjun

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Pajjiż *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Kunjom il-missier mat-twelid

[ BDT ] {{metaSection.fatherFamilyNameAtBirth.$$error}} {{metaSection.fatherFamilyNameAtBirth.$$warning}}

Isem il-missier

[ BDT ] {{metaSection.forenameFather.$$error}} {{metaSection.forenameFather.$$warning}}

Kunjom l-omm mat-twelid

[ BDT ] {{metaSection.motherFamilyNameAtBirth.$$error}} {{metaSection.motherFamilyNameAtBirth.$$warning}}

Isem l-omm

[ BDT ] {{metaSection.forenameMother.$$error}} {{metaSection.forenameMother.$$warning}}

Tagħrif addizzjonali dwar il-persuna [ SED ]

Nazzjonalità

[ ENUM ] {{metaSection.nationality.$$error}} {{metaSection.nationality.$$warning}}

Kunjom(ijiet) preċedenti

[ BDT ] {{metaSection.previousFamilyName.$$error}} {{metaSection.previousFamilyName.$$warning}}

Isem/ismijiet preċedenti

[ BDT ] {{metaSection.previousForename.$$error}} {{metaSection.previousForename.$$warning}}

Indirizz [ CC ]

Triq

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

Isem il-Bini

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

Belt *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Kodiċi postali

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

Reġjun

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Pajjiż *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Tagħrif ta' kuntatt dwar il-persuna [ CC ]

Numri tal-Telefown [ CC ]

Numru tat-Telefown [ CC ]

Tip

[ ENUM ] {{metaSection.type.$$error}} {{metaSection.type.$$warning}}

Għadd *

[ BDT ] {{metaSection.number.$$error}} {{metaSection.number.$$warning}}

Numru tat-Telefown

Indirizzi tal-posta elettronika [ CC ]

Indirizz tal-Posta Elettronika [ CC ]

Indirizz tal-Posta Elettronika

[ BDT ] {{metaSection.email.$$error}} {{metaSection.email.$$warning}}

Indirizz tal-Posta Elettronika

Il-benefiċċju kkonċernat * [ SED ]

Tip ta’ benefiċċju li b’riferiment għalih tintalab l-informazzjoni medika *

[ ENUM ] {{metaSection.typeBenefitInReferWhichMedicalInformationRequested.$$error}} {{metaSection.typeBenefitInReferWhichMedicalInformationRequested.$$warning}}

Natura tat-talba * [ SED ]

Nitolbuk biex *

[ ENUM ] {{metaSection.weAskTo.$$error}} {{metaSection.weAskTo.$$warning}}

Jekk jogħġbok agħti

[ ENUM ] {{metaSection.pleaseProvide.$$error}} {{metaSection.pleaseProvide.$$warning}}

Jekk jogħġbok imla li ġej jekk “Jekk jogħġbok agħtina” = “Evidenza Medika Oħra”: [ SED ]

Evidenza Medika Oħra

[ CDT ] {{metaSection.otherMedicalEvidence.$$error}} {{metaSection.otherMedicalEvidence.$$warning}}

Deskrizzjoni (rekwiżiti speċjali li għandhom jiġu segwiti u punti li għandhom jiġu koperti) tal-eżami mediku mitlub

[ CDT ] {{metaSection.specialRequirementsPointsCoveredFromMedicalExamination.$$error}} {{metaSection.specialRequirementsPointsCoveredFromMedicalExamination.$$warning}}

Perjodu kkonċernat * [ SED ]

L-evidenza/eżami medika/u mitluba t/jikkonċerna l-perjodu ta’ inkapaċità għax-xogħol * [ CC ]

Data tal-bidu *

[ BDT ] {{metaSection.startDate.$$error}} {{metaSection.startDate.$$warning}}

Data tat-tmiem *

[ BDT ] {{metaSection.endDate.$$error}} {{metaSection.endDate.$$warning}}

Aħna naqblu li nkopru l-kostijiet tal-evidenza medika/tal-eżami mediku *

[ ENUM ] {{metaSection.weAgreeCoverCostsMedicalEvidenceExamination.$$error}} {{metaSection.weAgreeCoverCostsMedicalEvidenceExamination.$$warning}}

Mistoqsijiet dwar benefiċċji tal-familja biss [ SED ]

Tagħrif mitlub *

[ ENUM ] {{metaSection.requestedInformation.$$error}} {{metaSection.requestedInformation.$$warning}}

Tagħrif addizzjonali mar-rapport mediku

[ CDT ] {{metaSection.additionalInformationMedicalReport.$$error}} {{metaSection.additionalInformationMedicalReport.$$warning}}

Mistoqsijiet dwar AWOD biss [ SED ]

Jekk jogħġbok imla t-taqsima li ġejja biss jekk it-talba tikkonċerna aċċident fuq ix-xogħol jew marda okkupazzjonali: [ SED ]

Dan is-SED jirrigwarda *

[ ENUM ] {{metaSection.thisSEDRelatedTo.$$error}} {{metaSection.thisSEDRelatedTo.$$warning}}

Data *

[ BDT ] {{metaSection.date.$$error}} {{metaSection.date.$$warning}}

Kodiċi tal-aċċident/marda

[ CDT ] {{metaSection.accidentDiseaseCode.$$error}} {{metaSection.accidentDiseaseCode.$$warning}}

Sistema ta' kodifikazzjoni tal-aċċident/marda

[ CDT ] {{metaSection.accidentDiseaseCodingSystem.$$error}} {{metaSection.accidentDiseaseCodingSystem.$$warning}}

Konsegwenzi tal-aċċident/tip jew deskrizzjoni qasira tal-marda

[ CDT ] {{metaSection.consequencesAccidentKindOrShortDescriptionDisease.$$error}} {{metaSection.consequencesAccidentKindOrShortDescriptionDisease.$$warning}}

Status tal-persuna

[ ENUM ] {{metaSection.statusPerson.$$error}} {{metaSection.statusPerson.$$warning}}

Jekk jogħġbok imla li ġej jekk “Status tal-persuna” = “Ieħor”: [ SED ]

Status tal-persuna (jekk "Ieħor")

[ CDT ] {{metaSection.statusPersonIfOther.$$error}} {{metaSection.statusPersonIfOther.$$warning}}

Impjegatur * [ CC ]

Isem *

[ CDT ] {{metaSection.name.$$error}} {{metaSection.name.$$warning}}

Numri ta’ identifikazzjoni [ CC ]

Numru ta’ identifikazzjoni [ CC ]

Għadd *

[ CDT ] {{metaSection.number.$$error}} {{metaSection.number.$$warning}}

Tip *

[ ENUM ] {{metaSection.type.$$error}} {{metaSection.type.$$warning}}

Numru ta’ identifikazzjoni

Indirizz [ CC ]

Triq

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

Isem il-Bini

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

Belt *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Kodiċi postali

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

Reġjun

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Pajjiż *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Tagħrif addizzjonali [ SED ]

Tagħrif addizzjonali

[ CDT ] {{metaSection.additionalInformation.$$error}} {{metaSection.additionalInformation.$$warning}}

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H120 - Talba għal Informazzjoni Medika Ir-Regolament (KE) Nru 883/04

H120 - Talba għal Informazzjoni Medika
Ir-Regolament (KE) Nru 883/04