Formulaire

Medical prescription for transport (Form 11574*06)

National Health Insurance Fund (Cnam) - Cerfa n° 11574*06
Autre numéro : S3138g

Form template (specimen) uploaded for information.

The original form must be used for your application.

The form contains an information leaflet n°50742#06.

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    Émetteur du formulaire administratif : Directorate for Legal and Administrative Information

    Verified 11 October 2022 - Directorate for Legal and Administrative Information (Prime Minister)