Funding For Treatment In The European Economic Area (Eea) Application Form Page 3

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Are you exempt from any
No
NHS charges (e.g.
prescription / dental /
Yes
Please provide reason for exemption:
ophthalmic charges)?
Evidence of exemption provided
For further guidance on exemptions (HC12):
Part 3: Treating Clinician / Provider Details
Please provide details of the main establishment(s) where you were treated / are going to
be treated (If this involves more than one establishment, please provide details on a separate
sheet)
Treating clinician name
Name of establishment
Address
Country
Telephone number(s)
Email address
Fax number
9a. EEA application form (10 /14)
Page 3 of 10

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