Formulaire

Application for reimbursement of medical transportation costs by personal vehicle and/or public transportation

Cerfa 11162*05 (S3140d)

  • Insured having used a transport for medical care or examinations or for return home after hospitalization
  • Service free
  • 5 steps
  • Language French
  • Taxi fees with an agreementThis form concerns the personal vehicle and/or public transport. For the costs of a conventional taxi, send the medical prescription and the invoice to the Health Insurance.

Fill out the form

Comment faire ?

  1. Fill out the online form
  2. Download the form
  3. Print it
  4. Sign it
  5. Send it to your health insurance fund

You must provide your health insurance fund with:

  • This form « Request for reimbursement of transport costs by personal vehicle and/or public transport » completed
  • The medical prescription for transport (form S3138) or the request for prior transport agreement as a medical prescription (form S3139 - part 3)
  • Your proof of payment (bus ticket, metro ticket, toll...) charge

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Verified 19 August 2026 - Public Service / (Prime Minister)