Formulaire

Application for prior approval for large appliances (Form 11164*04)

Cerfa 11164*04 (S3604d)

Form template uploaded for information

For your gait, you must use the original form provided by the healthcare professional.

    Fill out the form

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

    Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)

    Verified 08 April 2020 - Directorate for Legal and Administrative Information (Prime Minister)