Formulaire

Dental-maxillofacial orthopedic treatments - Request for prior agreement - Doctor

Cerfa 10522*01 (S 3155)

  • Public concernéInsurance policy
  • CoûtService free
  • Nombre d’étapes3 steps
  • LangueLanguage French

Fill out the form

Comment faire ?

  1. Have filled the form by the doctor
  2. Sign the form
  3. Send the form at the dental check of your health insurance fund
General scheme
Who shall I contact
Agricultural scheme
Who shall I contact

Et après ?

The cash register's response must be addressed by the 15th day following receipt of the form. Failure to reply within that period shall constitute an agreement.

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Verified 30 January 2026 - Public Service / Directorate of Legal and Administrative Information (Prime Minister)