Application For Reimbursement Of Medical Cost Abroad Vínlandsleið 16

application for reimbursement of medical cost abroad vínlandsleið 16 150 reykjavík phone 515-0000 [email protected]

Application for reimbursement of medical cost abroad

Vínlandsleið 16
150 Reykjavík
Phone 515-0000
[email protected]
www.sjukra.is
1. Name
 
2. ID number (Kennitala)
 
3. Residence in Iceland
 
4. Postal code
 
5. Place
 
6. Phone number
 
7. Email (Uppercase letters)
 
8. Country of stay:
 
9. Travel period:
From   To  
10. Reason of stay?
Student (confirmation of studies is required) Vacation Work Other,
what?  
11. Do you have travel insurance somewhere else? No Yes, with who?  
11.1. – If Yes, have you applied for reimbursement from that insurance
company? No Yes
* Please note that medical expenses may be included in the insurance
provided by the credit card companies when airfare is paid by credit
card.
Medical bills and receipt of payment must be submitted with the
application.
If other than the patient is to receive the reimbursement, then a
power of attorney must be submitted. If the patient is a child under
18 years old, then the child’s guardian will receive the
reimbursement.
12. Name
 
13. ID number
 
14. Residence, postal code, place
 
15. Bank information
Bank   hb.   Account number  
By his signature, the applicant gives the Icelandic Health insurance
authority to obtain the necessary information from the National
Registry, insurance companies and tax authorities.
16. Place and date
 
17. Signature
The applicant is responsible for ensuring that the information is true
and correct, cf. Paragraph 4 Article 34 Act no. 112/2008. Inadequate
or incorrect disclosure can result in a reimbursement claim by the
Icelandic Health Insurance as well as the payment of penalty interest,
cf. Articles 34 and 37. Act no. 112/2008.
Sjúkratryggingar Íslands Vínlandsleið 16 150 Reykjavík Tel: 515-0000
www.sjukra.is [email protected]