Claim for Reimbursement of Sickness Costs

Please do not leave any staple with the attached documents.

(One staple on a request form)

EUROCONTROL / Reserved for administration
SICKNESS INSURANCE SCHEME / Payroll Nr:

CLAIM FOR REIMBURSEMENT OF SICKNESS COSTS

[Article 28 of Rule No. 10]

Primary cover

/ if 100% cover, please indicate:
Reference number :

Complementary cover

/ Date of decision :
Claimant: / Surname: / Forename:
Claims Office: / BRXL / BRET / MAAS / INA
Tel Ext.
Contact Address (in case
of pensioners / others): / Tel.:

REIMBURSEMENT CLAIMEDPLEASE GROUP EXPENSES BY PATIENT

Patient’s firstname /

NATURE OF EXPENSES

(ex. consultation, home visit, pharmacy, examinations.) / Date
of Item / Ref. Nr.
Prior Autorisation / EXPENSES /

Amount of other insurance

Amount / Currency 
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother medical productother treatment / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatment / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
cons.gen.pract.cons.Spec.home visit G.P.home visit SpecMedicinesanalyses/radio/labohospitalisationdental costskine-physiospectacle framecontact lensesdisposable lensesconfinementpsychotherapyspeech therapymedical auxiliariesnursing attendancecureother treatmentother medical product / / / EURCHFCZKHUFNOKUSDCADOther Currency
 Fill in the amount in currency used;
it will be automatically converted. /

TOTAL (for all currencies)

Please do not carry out a carryforward on another form, each request being treated separately.

I, the undersigned, declare that this claim is completely truthful
and that payment has been made for all items attached.

Number of supporting
documents attached
(place and date) / Compulsory Signature

Sickness Insurance - Updated on 27/10/18