Application for reimbursement of costs

Enter the data and click "Continue". The mandatory data are marked with a star " * ". Where the data have the letter " i " next to them, you can read an additional explanation or tips for the entry of the data. The files containing evidence must be prepared in the PDF format. The maximum permitted size of an attachment is 3MB. Send your application by clicking "Submit". To be informed about the successfully received application via e-mail, indicate your e-mail address in the application.

 If the button "New row" appears above the data, you can click on it and a new entry field will appear where you can enter new medicine, medical device or another entitlement for which you are claiming the reimbursement. You can delete any unnecessary entry field or row, which you have inserted by mistake, by clicking the red icon with the waste bin symbol. The set of data referring to the type of reimbursement contains a list of attachments which must be attached to the application for the selected type of reimbursement. The mandatory attachments are marked with a star " ". We will notify you if you have attached incomplete attachments and ask you to attach the completed ones so that we can continue the procedure.