Formulaire

Care received abroad - Declaration to be completed by the insured

Cerfa 12267*06 (S3125th)

  • Any person requesting reimbursement (with supporting documents) at his cash register in case of care during a stay abroad
  • Free approach, with the exception of postage for postal items
  • Language French

Fill out the form

Comment faire ?

  1. Fill out the online form
  2. Download the form
  3. Print it
  4. Date and sign
  5. Send it to your health insurance fund with the documents to be attached

In all cases, the following documents must be attached:

  • Original Care Bills Paid
  • Medical prescriptions with care received
  • Proof of payment for treatment received in the country of stay (example: credit card ticket)
  • Possibly, posting form validated by your caisse.

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Verified 06 October 2026 - Public Service / (Prime Minister)