Formulaire

Spa treatment - Management questionnaire (accompanied by a declaration of resources). (Form 11139*03)

Cerfa 11139*03 (S3185c)

Form template posted online for information.

For your procedure, you must use the original form provided by your doctor.

The form contains an explanatory note (cerfa n°50270#03).

    Fill out the form

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

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    Je donne mon avis

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

    Verified 16 December 2025 - Public Service / Directorate of Legal and Administrative Information (Prime Minister)