Funding For Treatment In The European Economic Area (Eea) Application Form Page 6
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10Post Treatment Costs
Please note that you will only be reimbursed for items / treatments clearly recorded in this
section and supported by original receipts / proof of payment. Please also number / batch
your receipts to match your entries in the table below.
All of the entries must also be covered by a clinician’s letter / report (inc. medication).
In the table below you must list all the treatments individually for which you are
g)
claiming reimbursement and submit the original invoices, receipts / proof of payment
to which they relate (keeping copies for your own records).
Additionally, please provide English translations, where these are not in English.
Note: Reimbursement cannot be made without proof of payment e.g. via till receipt /
official dated stamp on the invoice or via a bank statement.
Receipt
Date of
Establishment paid
Treatment(s) covered
Amount paid
receipt
(in state
Number
currency)
Hôpital Européen
1)
20/01/14
Blood test
10,00 Euros
Georges-Pompidou
2)
3)
4)
Please continue on an additional sheet if you
TOTAL CLAIMED
need more space and tick here
9a. EEA application form (10 /14)
Page 6 of 10
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