Formulaire

Spa treatment - Support questionnaire (accompanied by a declaration of resources). (Form 11139*03)

Cerfa 11139*03 (S3185c)

Form template uploaded for information.

For your gait, you must use the original form provided by your doctor.

The form contains an explanatory note (cerfa n°50270#03).

    Fill out the 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 26 March 2024 - Directorate for Legal and Administrative Information (Prime Minister)