Formulaire
Medical prescription for transport (Form 11574*06)
Cerfa 11574*06 (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.
Contact the entity in charge of this form
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Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)
Verified 11 October 2022 - Directorate for Legal and Administrative Information (Prime Minister)