S3 EN

Coordination of Social Security Systems

Medical treatment for former cross-border worker in former country of work EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE HOLDER

This is your certificate of entitlement to certain medical treatment in your former State of work. If you present it to the health care institution at the place of stay, you will receive medical treatment under the same conditions as persons insured in that State. For a list of health care institutions, see http://ec.europa.eu/social-security-directory/

1. personal details of the holder

1.1 Personal Identification Number in the competent Member State

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth

1.6 Current address

1.6.1 Street, N° 1.6.3 Post code

1.6.2 Town 1.6.4 Country code

1.7 Personal Identification Number in the former Member State of work

1.8 Status

ο 1.8.1 Former cross-border worker ο 1.8.2 Family member of former cross-border worker

2. Treatment details

The person referred to above is entitled to

ο 2.1 continuation of treatment that began in former State of work, i.e. (***) 2.1.1 nature of treatment / illness

ο 2.2 treatment in the former State of work (***)

(*) Regulations (EC) No 883/2004, article 28, and 987/2009, article 29. (**) Information given to the institution by the holder when this is not known by the institution. (***) Please indicate the former Member State of work.

©European Commission

Coordination of Social Security Systems

Medical treatment for former cross-border worker in former country of work

3. Institution completing THE form

3.1 Name

3.2 Street, N°

3.3 Town

3.4 Post code 3.5 Country code

3.6 Institution ID

3.7 Office fax N°

3.8 Office phone N°

3.9 E-mail

3.10 Date

3.11 Signature

stamp