Formulaire
Care Sheet - Physician (Specimen) (Form 12541*02)
Cerfa 12541*02 (S3110j)
Form template uploaded for information. For your gait, you must use the original form submitted by your doctor (except for the Vitale teletransmission).
The form contains leaflet n°51070#02.
Contact the entity in charge of 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.
Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)
Verified 01 April 2020 - Directorate for Legal and Administrative Information (Prime Minister)