Formulaire

Declare your treating physician (Form 12485*03)

Cerfa 12485*03 (S3704b)

Form to be filled in with the doctor of your choice during a consultation.

The form contains a cerfa leaflet n°51041#03.

    Fill out the form

    To whom shall I send this form ?

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

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

    Verified 29 March 2021 - Directorate for Legal and Administrative Information (Prime Minister)